Basic Information
| Provider Information | |||||||||
| NPI: | 1649468018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | O'NEILL | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 25 RAILROAD AVE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028853206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012474278 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25 RAILROAD AVE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028853206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012474278 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2007 | ||||||||
| LastUpdateDate: | 10/10/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN43802 | RI | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | RR02204 | 05 | RI | MEDICAID |