Provider Demographics
NPI:1396801213
Name:KELLEY, SALLY ANN (MD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:ANN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:ANN
Other - Last Name:WIEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3809 W BUSINESS 83
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78552-3521
Mailing Address - Country:US
Mailing Address - Phone:956-504-3550
Mailing Address - Fax:956-734-9038
Practice Address - Street 1:3809 W BUSINESS 83
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78552-3521
Practice Address - Country:US
Practice Address - Phone:956-504-3550
Practice Address - Fax:956-734-9038
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR0040207RH0002X, 207RH0002X
IN01050090A207R00000X, 207RH0002X
IL036.128140207RH0002X
IL336.089764207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
532194YMVUOtherWELLMED NETWORKS INC
IN200369390Medicaid
IL450690013Medicare PIN
532194YMVUOtherWELLMED NETWORKS INC
IN940550F1Medicare PIN
IN200369390Medicaid