Provider Demographics
NPI:1700041670
Name:COMMON, KELLY LYNN (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:COMMON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-0130
Mailing Address - Country:US
Mailing Address - Phone:970-858-2186
Mailing Address - Fax:970-858-2208
Practice Address - Street 1:300 W OTTLEY AVE
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2118
Practice Address - Country:US
Practice Address - Phone:970-858-3900
Practice Address - Fax:970-858-2743
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT012538207R00000X
CODR.0048539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000160157Medicaid