Provider Demographics
NPI:1275021032
Name:MACDONNELL, KELLY LLIAN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LLIAN
Last Name:MACDONNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11839 201ST ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3526
Mailing Address - Country:US
Mailing Address - Phone:917-613-3539
Mailing Address - Fax:
Practice Address - Street 1:466 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10801-6431
Practice Address - Country:US
Practice Address - Phone:800-679-3609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program