Provider Demographics
NPI:1891794186
Name:KELLY, BONNIE L (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:722 YORKLYN RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:HOCKESSIN
Mailing Address - State:DE
Mailing Address - Zip Code:19707-8718
Mailing Address - Country:US
Mailing Address - Phone:302-235-2351
Mailing Address - Fax:302-235-2365
Practice Address - Street 1:722 YORKLYN RD
Practice Address - Street 2:SUITE 400
Practice Address - City:HOCKESSIN
Practice Address - State:DE
Practice Address - Zip Code:19707-8718
Practice Address - Country:US
Practice Address - Phone:302-235-2351
Practice Address - Fax:302-235-2365
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10006988207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000023592Medicaid
DE080132779OtherRAILROAD MEDICARE
DE012696Q26Medicare PIN
DE1000023592Medicaid