Healthcare Provider Details

I. General information

NPI: 1497142996
Provider Name (Legal Business Name): KEVIN KELLEY R.N., CDOE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BALD HILL RD SUITE 520
WARWICK RI
02886-1617
US

IV. Provider business mailing address

1 COMMERCE ST CENTRAL ADMINISTRATION
LINCOLN RI
02865-1186
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-8520
  • Fax: 401-793-8527
Mailing address:
  • Phone: 401-793-8392
  • Fax: 401-793-8391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN47992
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN47992
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN47992
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: