=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225790769
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DEKOTA KELLEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2021
-----------------------------------------------------
Last Update Date | 10/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 395 N 6TH ST
-----------------------------------------------------
City | WYTHEVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24382-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-620-7139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1045 S 4 1/2 ST
-----------------------------------------------------
City | WYTHEVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24382-3566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-228-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------