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General NPI Number Information
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NPI Number | 1487319869
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Entity Type | Individual
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Provider Name | LARRY WAYNE KELLY JR. PMHNP
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Gender | Male
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Dates
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Enumeration Date | 11/01/2021
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Last Update Date | 11/01/2021
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Provider Practice Location Address
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Address Line | 1423 PEGER RD
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City | FAIRBANKS
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State | AK
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Zip | 99709-5169
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Country | US
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Telephone | 907-371-1300
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Fax |
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Provider Business Mailing Address
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Address Line | 906 KINGDOM COME DR
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City | CUMBERLAND
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State | KY
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Zip | 40823-1547
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Country | US
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Telephone | 606-508-5204
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 183314
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License Number State | AK
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