Provider Demographics
NPI:1447354147
Name:KELLEY, MICHAEL THOMAS (NP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:KELLEY
Suffix:
Gender:M
Credentials:NP
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 1146
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25402-1146
Mailing Address - Country:US
Mailing Address - Phone:304-263-4999
Mailing Address - Fax:
Practice Address - Street 1:99 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2890
Practice Address - Country:US
Practice Address - Phone:304-263-4999
Practice Address - Fax:304-263-0984
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA170876163WA2000X
WV103811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator