Provider Demographics
NPI:1841887643
Name:STEVENS, KELLI LYNN
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:LYNN
Last Name:STEVENS
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:PO BOX 687
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25802-0687
Mailing Address - Country:US
Mailing Address - Phone:304-253-8979
Mailing Address - Fax:
Practice Address - Street 1:1289 ROBERT C BYRD DRIVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25802
Practice Address - Country:US
Practice Address - Phone:304-253-8979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-28
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3747P1801XMedicaid