Provider Demographics
NPI:1609611771
Name:O'CONNELL, KELLY LYNN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:O'CONNELL
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 1:601 LUKE ST APT 5
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-6812
Mailing Address - Country:US
Mailing Address - Phone:304-685-5069
Mailing Address - Fax:
Practice Address - Street 1:601 LUKE ST APT 5
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-6812
Practice Address - Country:US
Practice Address - Phone:304-685-5069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant