Provider Demographics
NPI:1215419031
Name:HALL, KELLEY MAE (MOTR/L)
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:MAE
Last Name:HALL
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:MISS
Other - First Name:KELLEY
Other - Middle Name:MAE
Other - Last Name:KULCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18275 S BURR STREET
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356
Mailing Address - Country:US
Mailing Address - Phone:219-696-6750
Mailing Address - Fax:
Practice Address - Street 1:2701 CHESTNUT STATION COURT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6395
Practice Address - Country:US
Practice Address - Phone:800-335-1060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005998A207NP0225X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology