Provider Demographics
NPI:1427758184
Name:NORTHERN, KELLY RENEE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:NORTHERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4240 WILLOWWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HINTON
Mailing Address - State:WV
Mailing Address - Zip Code:25951-5235
Mailing Address - Country:US
Mailing Address - Phone:540-580-8059
Mailing Address - Fax:
Practice Address - Street 1:4240 WILLOWWOOD RD
Practice Address - Street 2:
Practice Address - City:HINTON
Practice Address - State:WV
Practice Address - Zip Code:25951-5235
Practice Address - Country:US
Practice Address - Phone:540-580-8059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant