Provider Demographics
NPI:1710185053
Name:MCKELL, BERNADETTE SUZANNE (DO)
Entity Type:Individual
Prefix:DR
First Name:BERNADETTE
Middle Name:SUZANNE
Last Name:MCKELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:80 CABRILLO HWY N STE I
Mailing Address - Street 2:
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019-1666
Mailing Address - Country:US
Mailing Address - Phone:650-276-0170
Mailing Address - Fax:650-440-4887
Practice Address - Street 1:80 CABRILLO HWY N STE I
Practice Address - Street 2:
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-1666
Practice Address - Country:US
Practice Address - Phone:650-276-0170
Practice Address - Fax:650-440-4887
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-09
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A12893207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1710185053OtherNPI