Provider Demographics
NPI:1790961894
Name:BURNETT, KELLI
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:
Last Name:BURNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 STOKES ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-9118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 310
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-9679
Practice Address - Country:US
Practice Address - Phone:304-235-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-18
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV62888163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9700002000Medicaid