Provider Demographics
NPI:1114792363
Name:O'CONNOR, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5855 VALLEY DR UNIT 2179
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-3673
Mailing Address - Country:US
Mailing Address - Phone:707-791-4599
Mailing Address - Fax:
Practice Address - Street 1:5855 VALLEY DR UNIT 2179
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-3673
Practice Address - Country:US
Practice Address - Phone:707-791-4599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide