Provider Demographics
NPI:1912187097
Name:RENNIE, KELLY VICTORIA (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:VICTORIA
Last Name:RENNIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 WASHINGTON ST E
Mailing Address - Street 2:SUITE 208
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1834
Mailing Address - Country:US
Mailing Address - Phone:304-388-7270
Mailing Address - Fax:
Practice Address - Street 1:1201 WASHINGTON ST E
Practice Address - Street 2:SUITE 208
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1834
Practice Address - Country:US
Practice Address - Phone:304-388-7270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-06
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPGY.1.TUL-SURG208600000X
WV260752086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery