Provider Demographics
NPI:1700226131
Name:O'DELL, KELLY NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:NICOLE
Last Name:O'DELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:4222 FAIRBANKS DR
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-2811
Practice Address - Country:US
Practice Address - Phone:770-534-6053
Practice Address - Fax:770-534-6050
Is Sole Proprietor?:No
Enumeration Date:2013-06-29
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125063367207Q00000X
IL036141396207Q00000X
GA83884207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine