Provider Demographics
NPI:1023870128
Name:KELLEY, COLLEEN E (BCO)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:E
Last Name:KELLEY
Suffix:
Gender:F
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 WALNUT ST STE 1801
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3612
Mailing Address - Country:US
Mailing Address - Phone:215-643-5556
Mailing Address - Fax:215-540-4566
Practice Address - Street 1:1528 WALNUT ST STE 1801
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3612
Practice Address - Country:US
Practice Address - Phone:215-643-5556
Practice Address - Fax:215-540-4566
Is Sole Proprietor?:No
Enumeration Date:2024-01-25
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
18390156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist