Provider Demographics
NPI:1649529108
Name:KELLEY, JOAN IRENE (RN)
Entity type:Individual
Prefix:MS
First Name:JOAN
Middle Name:IRENE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3483 PRESERVE RUN TRAIL
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052
Mailing Address - Country:US
Mailing Address - Phone:614-806-1355
Mailing Address - Fax:
Practice Address - Street 1:175 GWINNETT DR.
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8444
Practice Address - Country:US
Practice Address - Phone:770-339-2395
Practice Address - Fax:678-990-3997
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN104467163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse