Provider Demographics
NPI:1770841165
Name:MAZZARELLA, KELLY M (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:MAZZARELLA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:STONEHAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-5347
Mailing Address - Country:US
Mailing Address - Phone:214-730-5437
Mailing Address - Fax:
Practice Address - Street 1:5323 HARRY HINES BLVD STOP 7200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7200
Practice Address - Country:US
Practice Address - Phone:214-730-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS1514208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics