Provider Demographics
NPI:1760073910
Name:DERONDA, KELLY SUE (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:DERONDA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 BEEKMAN PLACE
Mailing Address - Street 2:
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414
Mailing Address - Country:US
Mailing Address - Phone:304-820-6861
Mailing Address - Fax:
Practice Address - Street 1:52 CARSON CIRCLE
Practice Address - Street 2:
Practice Address - City:RANSON
Practice Address - State:WV
Practice Address - Zip Code:25438
Practice Address - Country:US
Practice Address - Phone:304-820-6861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-31
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant