Healthcare Provider Details

I. General information

NPI: 1215396072
Provider Name (Legal Business Name): KELLY L. RIEGLEMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY J LAURENT MD

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-1574
  • Fax:
Mailing address:
  • Phone: 937-257-1574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number30231
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number30231
License Number StateNE

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: