Provider Demographics
NPI:1013210822
Name:KLOCEK, KELLY ANNE (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANNE
Last Name:KLOCEK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:VANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13 CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5313
Mailing Address - Country:US
Mailing Address - Phone:815-216-6136
Mailing Address - Fax:
Practice Address - Street 1:2000 EOFF ST
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-3823
Practice Address - Country:US
Practice Address - Phone:304-234-8177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17036207P00000X
OH58-003772207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine