Healthcare Provider Details

I. General information

NPI: 1710333570
Provider Name (Legal Business Name): KATHRYN LYONS KELLY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2016
Last Update Date: 04/08/2020
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

IV. Provider business mailing address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 401-737-7010
  • Fax:
Mailing address:
  • Phone: 401-737-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberLP03615
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberETL00004
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: