Healthcare Provider Details

I. General information

NPI: 1114021417
Provider Name (Legal Business Name): REBECCA ANN KELLEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 E BROAD ST
NAYLOR MO
63953
US

IV. Provider business mailing address

1715 BIG BEND RD
POPLAR BLUFF MO
63901-2916
US

V. Phone/Fax

Practice location:
  • Phone: 573-399-2311
  • Fax: 573-399-2646
Mailing address:
  • Phone: 573-778-0995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number151395
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: