Provider Demographics
NPI:1487319869
Name:KELLY, LARRY WAYNE JR (PMHNP)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:WAYNE
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 KINGDOM COME DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:KY
Mailing Address - Zip Code:40823-1547
Mailing Address - Country:US
Mailing Address - Phone:606-508-5204
Mailing Address - Fax:
Practice Address - Street 1:1423 PEGER RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5169
Practice Address - Country:US
Practice Address - Phone:907-371-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK183314363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health