Provider Demographics
NPI:1861482366
Name:LU, KELLY MCGOVERN (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MCGOVERN
Last Name:LU
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3128 JERSEY ST
Mailing Address - Street 2:
Mailing Address - City:PANTON
Mailing Address - State:VT
Mailing Address - Zip Code:05491-9331
Mailing Address - Country:US
Mailing Address - Phone:802-475-2118
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:VERMONT CHILDREN'S HOSPITAL
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-6081
Practice Address - Fax:802-847-5805
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN10515363L00000X
VT1010032226363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q26307Medicare UPIN