Provider Demographics
NPI:1932549565
Name:KELLY, INGRID (OTR)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ANACONDA
Mailing Address - State:MT
Mailing Address - Zip Code:59711-1804
Mailing Address - Country:US
Mailing Address - Phone:406-240-8738
Mailing Address - Fax:
Practice Address - Street 1:1300 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-1804
Practice Address - Country:US
Practice Address - Phone:406-240-8738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV120196283X00000X
PAOC012789314000000X
HI1047314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No283X00000XHospitalsRehabilitation Hospital