Basic Information
| Provider Information | |||||||||
| NPI: | 1750772380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLEY | ||||||||
| FirstName: | WHITLEE | ||||||||
| MiddleName: | LAINA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 112 TITAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562757089 | ||||||||
| FaxNumber: | 2563410747 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 TITAN DRIVE | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562757089 | ||||||||
| FaxNumber: | 2563410747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2015 | ||||||||
| LastUpdateDate: | 04/24/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/10/2018 | ||||||||
| NPIReactivationDate: | 04/24/2019 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 106E00000X | Y |
No ID Information.