Provider Demographics
NPI:1306455159
Name:SUMMERS, KELLY SUE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:SUMMERS
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 1:1205 9TH ST APT 502
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-2158
Mailing Address - Country:US
Mailing Address - Phone:304-991-1576
Mailing Address - Fax:
Practice Address - Street 1:1205 9TH ST APT 502
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-2158
Practice Address - Country:US
Practice Address - Phone:304-991-1576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant