Provider Demographics
NPI:1588652499
Name:FOURNIER, KELLI L (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:L
Last Name:FOURNIER
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 1:3136 WEST ST
Mailing Address - Street 2:
Mailing Address - City:WEIRTON
Mailing Address - State:WV
Mailing Address - Zip Code:26062-4637
Mailing Address - Country:US
Mailing Address - Phone:304-748-2828
Mailing Address - Fax:304-797-0002
Practice Address - Street 1:3136 WEST ST
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-4637
Practice Address - Country:US
Practice Address - Phone:304-748-2828
Practice Address - Fax:304-797-0002
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV19925207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2003092000Medicaid
OH2194012Medicaid
WVFO4080502Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
OH2194012Medicaid