Provider Demographics
NPI:1114551397
Name:O'DONNELL, KELLY (LMT)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:386 ERIE ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2927
Mailing Address - Country:US
Mailing Address - Phone:631-766-4235
Mailing Address - Fax:
Practice Address - Street 1:1 MOUNT MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2107
Practice Address - Country:US
Practice Address - Phone:631-766-4235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311363-1164W00000X
NY012679-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No164W00000XNursing Service ProvidersLicensed Practical Nurse