Provider Demographics
NPI:1033927462
Name:KELLEY, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2430 S CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:EATON RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:48827-8342
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:WV
Practice Address - Zip Code:26074-1082
Practice Address - Country:US
Practice Address - Phone:517-582-4685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program