Healthcare Provider Details

I. General information

NPI: 1013562727
Provider Name (Legal Business Name): KELLEY BOYD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

297 S MAIN ST
SHERIDAN WY
82801-4832
US

IV. Provider business mailing address

748 S THURMOND ST
SHERIDAN WY
82801-5061
US

V. Phone/Fax

Practice location:
  • Phone: 307-672-5169
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number31215
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: