Healthcare Provider Details

I. General information

NPI: 1568809515
Provider Name (Legal Business Name): KELLY CORBETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2013
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5599
  • Fax:
Mailing address:
  • Phone: 603-650-5599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9722545-1205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLP02908
License Number StateRI
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19879
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: