Provider Demographics
NPI:1174920763
Name:KELLEY, ANGELA (M ED)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 SOUTH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:PATASKALA
Mailing Address - State:OH
Mailing Address - Zip Code:43062-6014
Mailing Address - Country:US
Mailing Address - Phone:740-964-3457
Mailing Address - Fax:
Practice Address - Street 1:927 SOUTH ST UNIT A
Practice Address - Street 2:
Practice Address - City:PATASKALA
Practice Address - State:OH
Practice Address - Zip Code:43062-6014
Practice Address - Country:US
Practice Address - Phone:740-964-3457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1503556174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist