Provider Demographics
NPI:1740694850
Name:KELLEY, RACHEL LYNN (DO)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:LYNN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 TOWN CENTER DR STE 203
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 MANATEE AVE W STE 202
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8624
Practice Address - Country:US
Practice Address - Phone:941-748-2455
Practice Address - Fax:941-746-4554
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101021127207Q00000X
FLOS16250207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS16250OtherLICENSE