Healthcare Provider Details

I. General information

NPI: 1154655512
Provider Name (Legal Business Name): AMY KRISTINE KELLEY RPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 02/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3728 N PRINCE ST
CLOVIS NM
88101-9744
US

IV. Provider business mailing address

2320 FAIRWAY TER
CLOVIS NM
88101-2724
US

V. Phone/Fax

Practice location:
  • Phone: 575-769-2389
  • Fax:
Mailing address:
  • Phone: 575-763-4161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5544
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: