Provider Demographics
NPI:1912461450
Name:KELLY, KAYLA N (MED)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:N
Last Name:KELLY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 WEST RD
Mailing Address - Street 2:
Mailing Address - City:LONDONDERRY
Mailing Address - State:NH
Mailing Address - Zip Code:03053-3114
Mailing Address - Country:US
Mailing Address - Phone:603-508-8167
Mailing Address - Fax:
Practice Address - Street 1:42 WEST RD
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-3114
Practice Address - Country:US
Practice Address - Phone:603-508-8167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician