Provider Demographics
NPI:1366214561
Name:KELLY, DIANA LYNN
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 S OAK ST APT C
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TN
Mailing Address - Zip Code:37874-2404
Mailing Address - Country:US
Mailing Address - Phone:559-362-3901
Mailing Address - Fax:
Practice Address - Street 1:4233 HIGHWAY 411
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37354-1571
Practice Address - Country:US
Practice Address - Phone:423-442-8082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health