Provider Demographics
NPI:1891682530
Name:WELLS, KELLY NICOLE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:WELLS
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 1:1217 BASSWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-5102
Mailing Address - Country:US
Mailing Address - Phone:757-692-1013
Mailing Address - Fax:
Practice Address - Street 1:2200 COLONIAL AVE STE 12K
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1919
Practice Address - Country:US
Practice Address - Phone:757-937-5780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0704015470390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program