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NPI Code Detail

MEDICARE: DR. KELLY NICOLE O'DELL M.D.

MEDICARE: DR. KELLY NICOLE O'DELL M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine Physician125063367IL
2207Q00000XFamily Medicine Physician036141396IL
3207Q00000XFamily Medicine Physician83884GA

General Provider Information

NPI Number : 1700226131
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KELLY NICOLE O'DELL M.D.
Provider Business Mailing Address
First Line : PO BOX 658
Second Line :
City : GAINESVILLE
State : GA
Zip : 30503-0658
Country : US
Telephone Number : 770-718-1122
Fax Number : 770-533-4786
Provider Business Practice Location Address
First Line : 4222 FAIRBANKS DR
Second Line :
City : OAKWOOD
State : GA
Zip : 30566-2811
Country : US
Telephone Number : 770-534-6053
Fax Number : 770-534-6050
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/29/2013
Last Update Date : 08/08/2022

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