Healthcare Provider Details

I. General information

NPI: 1245626225
Provider Name (Legal Business Name): KATHLEEN KELLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 12/18/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4322 S LAFAYETTE BLVD
SOUTH BEND IN
46614
US

IV. Provider business mailing address

1602 WAYNE ST
SOUTH BEND IN
46615-1334
US

V. Phone/Fax

Practice location:
  • Phone: 574-391-1111
  • Fax: 574-859-5040
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01082520A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: