Provider Demographics
NPI:1043848039
Name:O'CONNELL, KELLY DORIS (RDN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DORIS
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 MILES ST
Mailing Address - Street 2:
Mailing Address - City:DAMARISCOTTA
Mailing Address - State:ME
Mailing Address - Zip Code:04543-4047
Mailing Address - Country:US
Mailing Address - Phone:207-563-1234
Mailing Address - Fax:
Practice Address - Street 1:41 DONALD B DEAN DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3252
Practice Address - Country:US
Practice Address - Phone:207-661-6064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-27
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI149133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered