Provider Demographics
NPI:1497952576
Name:REYNOLDS, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:GILLICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2200 GAR HWY
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02777-3935
Mailing Address - Country:US
Mailing Address - Phone:508-379-9605
Mailing Address - Fax:508-379-9813
Practice Address - Street 1:2200 GAR HWY
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:MA
Practice Address - Zip Code:02777-3935
Practice Address - Country:US
Practice Address - Phone:508-379-9605
Practice Address - Fax:508-379-9813
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA244246208000000X
MA232586208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics