Provider Demographics
NPI:1619193869
Name:WOOD, KELLY ANN (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WOOD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:521 N BORDERS AVE STE C
Mailing Address - Street 2:MARISSA MEDICAL CLINIC
Mailing Address - City:MARISSA
Mailing Address - State:IL
Mailing Address - Zip Code:62257-1195
Mailing Address - Country:US
Mailing Address - Phone:618-295-1591
Mailing Address - Fax:
Practice Address - Street 1:521 N BORDERS AVE STE C
Practice Address - Street 2:MARISSA MEDICAL CLINIC
Practice Address - City:MARISSA
Practice Address - State:IL
Practice Address - Zip Code:62257-1195
Practice Address - Country:US
Practice Address - Phone:618-295-1591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-123456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine