Provider Demographics
NPI:1861884546
Name:O'CONNELL, KELLY ANNE (CRNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SHURS LN STE 203
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19127-2123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 SHURS LN STE 203
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19127-2123
Practice Address - Country:US
Practice Address - Phone:215-482-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-04
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN628832163W00000X
PASP019217363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse