Provider Demographics
NPI:1336478114
Name:KELLY, FIONNUALA ANN (MD)
Entity Type:Individual
Prefix:
First Name:FIONNUALA
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E 9TH CT
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-4510
Mailing Address - Country:US
Mailing Address - Phone:630-325-3434
Mailing Address - Fax:630-325-3434
Practice Address - Street 1:230 E 9TH CT
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-4510
Practice Address - Country:US
Practice Address - Phone:630-325-3434
Practice Address - Fax:630-325-3434
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-068717208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice