Provider Demographics
NPI:1821836487
Name:O'DONNELL, KALEY JANE (PA-C)
Entity type:Individual
Prefix:
First Name:KALEY
Middle Name:JANE
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 GROSS POINT RD # 4517
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1214
Mailing Address - Country:US
Mailing Address - Phone:847-677-9600
Mailing Address - Fax:
Practice Address - Street 1:9600 GROSS POINT RD # 4517
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1214
Practice Address - Country:US
Practice Address - Phone:847-677-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085010575363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant