Provider Demographics
NPI:1720857998
Name:KELLY, MELISSA ANN (PHD, HCLD/CC(ABB))
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:PHD, HCLD/CC(ABB)
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:DIEDERICHS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:114 AMELIA DR
Mailing Address - Street 2:
Mailing Address - City:HARVEST
Mailing Address - State:AL
Mailing Address - Zip Code:35749-3216
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 AMELIA DR
Practice Address - Street 2:
Practice Address - City:HARVEST
Practice Address - State:AL
Practice Address - Zip Code:35749-3216
Practice Address - Country:US
Practice Address - Phone:920-904-0856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20213064207SG0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular Genetics