Provider Demographics
NPI:1265413272
Name:KELLEY, KIMBERLY RENEE (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENEE
Last Name:KELLEY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92-1001 ALIINUI DR APT 17B
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-2255
Mailing Address - Country:US
Mailing Address - Phone:808-292-3192
Mailing Address - Fax:
Practice Address - Street 1:1 JARRETT WHITE RD
Practice Address - Street 2:TRIPLER ARMY MEDICAL CENTER
Practice Address - City:TRIPLER AMC
Practice Address - State:HI
Practice Address - Zip Code:96859-5001
Practice Address - Country:US
Practice Address - Phone:808-433-2460
Practice Address - Fax:808-433-1558
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055699207L00000X
IN01095424A207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADOOOMedicare UPIN