Provider Demographics
NPI:1619264041
Name:KELLY, CAROLYN (DPM)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 REMINGTON BLVD STE 370
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4302
Mailing Address - Country:US
Mailing Address - Phone:630-418-6601
Mailing Address - Fax:630-312-2223
Practice Address - Street 1:396 REMINGTON BLVD STE 370
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4302
Practice Address - Country:US
Practice Address - Phone:630-418-6601
Practice Address - Fax:630-312-2223
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005524213ES0131X
IL135000752213E00000X
IL016.005524213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist