Provider Demographics
NPI:1154144814
Name:KELLY, ANDREA (CPM, LM)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:DREA
Other - Middle Name:
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2200 LARSTON LN
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-6035
Mailing Address - Country:US
Mailing Address - Phone:480-688-7225
Mailing Address - Fax:
Practice Address - Street 1:2200 LARSTON LN
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-6035
Practice Address - Country:US
Practice Address - Phone:480-688-7225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99578176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife