Provider Demographics
NPI:1114386794
Name:MCDERMOTT, KELLY JO
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:KRETCHMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:525 N FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-2966
Mailing Address - Country:US
Mailing Address - Phone:605-995-5701
Mailing Address - Fax:605-995-5700
Practice Address - Street 1:525 N FOSTER ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-2966
Practice Address - Country:US
Practice Address - Phone:605-995-5701
Practice Address - Fax:605-995-5700
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001027363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily