Healthcare Provider Details

I. General information

NPI: 1447145131
Provider Name (Legal Business Name): STACEY KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 06/11/2025
Certification Date: 06/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7905 L ST STE 420
OMAHA NE
68127-1732
US

IV. Provider business mailing address

4231 S 12TH ST
OMAHA NE
68107-2310
US

V. Phone/Fax

Practice location:
  • Phone: 402-515-2654
  • Fax:
Mailing address:
  • Phone: 402-801-6044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: