Provider Demographics
NPI:1730430059
Name:AVANT, KELLI DALE (RPH)
Entity type:Individual
Prefix:MISS
First Name:KELLI
Middle Name:DALE
Last Name:AVANT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 N GRIMES ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-2716
Mailing Address - Country:US
Mailing Address - Phone:575-393-1576
Mailing Address - Fax:
Practice Address - Street 1:2220 N GRIMES ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-2716
Practice Address - Country:US
Practice Address - Phone:575-393-1576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM00007763183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist