Provider Demographics
NPI:1548200074
Name:KELLY, SUSAN C (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:7 WEAVER RD
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-7135
Mailing Address - Country:US
Mailing Address - Phone:401-667-0905
Mailing Address - Fax:401-667-0590
Practice Address - Street 1:7 WEAVER RD
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-7135
Practice Address - Country:US
Practice Address - Phone:401-667-0905
Practice Address - Fax:401-667-0590
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIDO00604207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology