Provider Demographics
NPI:1679801740
Name:WADE, KELLY L (BA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:WADE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-2023
Mailing Address - Country:US
Mailing Address - Phone:574-522-0104
Mailing Address - Fax:574-522-1902
Practice Address - Street 1:1400 HUDSON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-2023
Practice Address - Country:US
Practice Address - Phone:574-522-0104
Practice Address - Fax:574-522-1902
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator