Provider Demographics
NPI:1982944955
Name:MADDOX, KELLY S
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:MADDOX
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 1:5145 COUNTY ROAD 49
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43324-9787
Mailing Address - Country:US
Mailing Address - Phone:937-441-2912
Mailing Address - Fax:
Practice Address - Street 1:5145 COUNTY ROAD 49
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43324-9787
Practice Address - Country:US
Practice Address - Phone:937-441-2912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH192059164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse