Provider Demographics
NPI:1053155853
Name:KELLY, JOYACELYN RYAN
Entity type:Individual
Prefix:
First Name:JOYACELYN
Middle Name:RYAN
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 1:12406 BERRY LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77014-3699
Mailing Address - Country:US
Mailing Address - Phone:832-859-8268
Mailing Address - Fax:
Practice Address - Street 1:12406 BERRY LAUREL LN
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77014-3699
Practice Address - Country:US
Practice Address - Phone:832-859-8268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver