Basic Information
| Provider Information | |||||||||
| NPI: | 1699813212 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | TRACEY | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 FOREST LAKE DR | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405156299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592733774 | ||||||||
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| Practice Location | |||||||||
| Address1: | 845 ANGLIANA AVE | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405083146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593239321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2007 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1264 | KY | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 207RA0401X | 3003542 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 363LF0000X | 3003542 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.