Provider Demographics
NPI:1740647122
Name:KELLEY, NICOLE ROSE
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ROSE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02081-3108
Mailing Address - Country:US
Mailing Address - Phone:508-641-3176
Mailing Address - Fax:
Practice Address - Street 1:63 EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02081
Practice Address - Country:US
Practice Address - Phone:508-641-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist