Provider Demographics
NPI:1932459559
Name:O'CONNELL, KELLY LYNNE (PA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNNE
Last Name:O'CONNELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNNE
Other - Last Name:SHEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:46 PLEASANTVIEW ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-4714
Mailing Address - Country:US
Mailing Address - Phone:339-226-0139
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6110
Practice Address - Country:US
Practice Address - Phone:617-732-5500
Practice Address - Fax:617-582-6021
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical