Provider Demographics
NPI:1104578533
Name:MCDONOUGH, KELLY S (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:S
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 HENLEY DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-4520
Mailing Address - Country:US
Mailing Address - Phone:619-952-4030
Mailing Address - Fax:
Practice Address - Street 1:5811 HENLEY DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-4520
Practice Address - Country:US
Practice Address - Phone:619-952-4030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA821911163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse