Provider Demographics
NPI:1386403731
Name:KELLY, VICTORIA MARIE
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:MARIE
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:PO BOX 856
Mailing Address - Street 2:
Mailing Address - City:MARKHAM
Mailing Address - State:TX
Mailing Address - Zip Code:77456-0856
Mailing Address - Country:US
Mailing Address - Phone:979-330-6039
Mailing Address - Fax:
Practice Address - Street 1:917 10TH ST
Practice Address - Street 2:
Practice Address - City:MARKHAM
Practice Address - State:TX
Practice Address - Zip Code:77456
Practice Address - Country:US
Practice Address - Phone:979-330-6039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64658246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy