Provider Demographics
NPI:1669539094
Name:KELLEY, VIVIAN A (NP)
Entity type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:A
Last Name:KELLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:VIVIAN
Other - Middle Name:A
Other - Last Name:BRUCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 W. HOSPITAL ROAD
Mailing Address - Street 2:EISENHOWER ARMY MEDICAL CENTER ATTN CREDENTIALS
Mailing Address - City:FORT GORDON
Mailing Address - State:GA
Mailing Address - Zip Code:30905-5650
Mailing Address - Country:US
Mailing Address - Phone:706-787-2720
Mailing Address - Fax:706-787-8176
Practice Address - Street 1:300 W HOSPITAL ROAD
Practice Address - Street 2:EISENHOWER ARMY MEDICAL CENTER ATTN CREDENTIALS
Practice Address - City:FORT GORDON
Practice Address - State:GA
Practice Address - Zip Code:30905-5650
Practice Address - Country:US
Practice Address - Phone:706-787-2720
Practice Address - Fax:706-787-8176
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN159555363LF0000X
AL1-050977372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Not Answered372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD 000Medicare UPIN