MEDICARE: MARIAH KELLEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN175541	CO

General Provider Information

NPI Number	:	1043671795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIAH KELLEY

Provider Business Mailing Address
First Line	:	9788 S CRYSTAL LAKE DR
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80125-8429
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9788 S CRYSTAL LAKE DR
Second Line	:
City	:	LITTLETON
State	:	CO
Zip	:	80125-8429
Country	:	US
Telephone Number	:	303-204-3355
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2016
Last Update Date	:	03/09/2016

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