Healthcare Provider Details

I. General information

NPI: 1619801560
Provider Name (Legal Business Name): BLUE CYPRESS IV AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N HAMILTON ST STE 1
GEORGETOWN KY
40324-1709
US

IV. Provider business mailing address

111 N HAMILTON ST STE 1
GEORGETOWN KY
40324-1709
US

V. Phone/Fax

Practice location:
  • Phone: 502-603-0027
  • Fax:
Mailing address:
  • Phone: 502-603-0027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MECHELLE KELLEY
Title or Position: OWNER/CEO
Credential: RN
Phone: 502-603-0027