Provider Demographics
NPI:1295853620
Name:MCGOWAN, KELLY JO
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:MCGOWAN
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 1:3634 JUNIOR FURNACE POWELLSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN FURNACE
Mailing Address - State:OH
Mailing Address - Zip Code:45629-8768
Mailing Address - Country:US
Mailing Address - Phone:740-574-2643
Mailing Address - Fax:
Practice Address - Street 1:3038 GALLIA ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4813
Practice Address - Country:US
Practice Address - Phone:740-355-0835
Practice Address - Fax:740-355-0835
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121293164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse