Provider Demographics
NPI:1952969826
Name:KELLY, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4048 CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-8122
Mailing Address - Country:US
Mailing Address - Phone:715-370-5646
Mailing Address - Fax:
Practice Address - Street 1:4048 CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-8122
Practice Address - Country:US
Practice Address - Phone:715-370-5646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker