Healthcare Provider Details

I. General information

NPI: 1699813212
Provider Name (Legal Business Name): SANDRA TRACEY KELLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 ANGLIANA AVE
LEXINGTON KY
40508-3146
US

IV. Provider business mailing address

801 FOREST LAKE DR
LEXINGTON KY
40515-6299
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9321
  • Fax:
Mailing address:
  • Phone: 859-273-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3003542
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1264
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number3003542
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: