Healthcare Provider Details

I. General information

NPI: 1689911232
Provider Name (Legal Business Name): LIFE'S JOURNEY OBGYN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 WEST PARK AVENUE SUITE 9
DUBOIS PA
15801
US

IV. Provider business mailing address

190 WEST PARK AVENUE SUITE 9
DUBOIS PA
15801
US

V. Phone/Fax

Practice location:
  • Phone: 814-371-1900
  • Fax: 814-503-8568
Mailing address:
  • Phone: 814-371-1900
  • Fax: 814-503-8568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberOS014455
License Number StatePA

VIII. Authorized Official

Name: DR. KELLY DAWN DUCKETT
Title or Position: OWNER
Credential: D.O.
Phone: 814-371-1900