Provider Demographics
NPI:1013515337
Name:COTTRELL, KELLY RENEE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:COTTRELL
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 1:504 JENNA WAY
Mailing Address - Street 2:
Mailing Address - City:SISSONVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25320-9311
Mailing Address - Country:US
Mailing Address - Phone:304-400-2999
Mailing Address - Fax:
Practice Address - Street 1:504 JENNA WAY
Practice Address - Street 2:
Practice Address - City:SISSONVILLE
Practice Address - State:WV
Practice Address - Zip Code:25320-9311
Practice Address - Country:US
Practice Address - Phone:304-400-2999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant