Provider Demographics
NPI:1679595169
Name:KELLIE, SUSAN MARGARET (MD, MPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARGARET
Last Name:KELLIE
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 CAMINO ALTO
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-7513
Mailing Address - Country:US
Mailing Address - Phone:505-967-9603
Mailing Address - Fax:
Practice Address - Street 1:163 CAMINO ALTO
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-7513
Practice Address - Country:US
Practice Address - Phone:505-967-9603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM92-264207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease