Healthcare Provider Details

I. General information

NPI: 1417654237
Provider Name (Legal Business Name): AMANDA KAY KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 02/13/2023
Certification Date: 02/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

298 MEDLEY CT
VINE GROVE KY
40175-8421
US

IV. Provider business mailing address

128 CRESTVIEW DR
BRANDENBURG KY
40108-1216
US

V. Phone/Fax

Practice location:
  • Phone: 270-352-1133
  • Fax:
Mailing address:
  • Phone: 270-945-5099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number23-256142
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: