Provider Demographics
NPI:1659373041
Name:O'CONNELL, KATELYN MAY (PAC)
Entity Type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:MAY
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:KATELYN
Other - Middle Name:MAY
Other - Last Name:BELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:550 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3186
Mailing Address - Country:US
Mailing Address - Phone:630-323-6116
Mailing Address - Fax:630-323-6169
Practice Address - Street 1:550 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3186
Practice Address - Country:US
Practice Address - Phone:630-323-6116
Practice Address - Fax:630-323-6169
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002187363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00378570OtherRAILROAD
ILK35220Medicare PIN