Healthcare Provider Details

I. General information

NPI: 1710020474
Provider Name (Legal Business Name): LAURA GAIL KELLIE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 DUTCHMANS PKWY SUITE 15
LOUISVILLE KY
40205-3340
US

IV. Provider business mailing address

PO BOX 950293
LOUISVILLE KY
40295-0293
US

V. Phone/Fax

Practice location:
  • Phone: 502-895-0524
  • Fax: 502-897-5798
Mailing address:
  • Phone: 405-682-3303
  • Fax: 405-792-8993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40675
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: