Provider Demographics
NPI:1689552598
Name:KELLEY, LATRIVIA DAWN
Entity type:Individual
Prefix:
First Name:LATRIVIA
Middle Name:DAWN
Last Name:KELLEY
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 1:814 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75224-3339
Mailing Address - Country:US
Mailing Address - Phone:214-980-2869
Mailing Address - Fax:214-980-2869
Practice Address - Street 1:814 RYAN RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75224-3339
Practice Address - Country:US
Practice Address - Phone:214-980-2869
Practice Address - Fax:214-980-2869
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-27
Last Update Date:2025-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1143333332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies