1861757148 NPI number — KELLY RENNICK O'BERRY LISW

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861757148 NPI number — KELLY RENNICK O'BERRY LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'BERRY
Provider First Name:
KELLY
Provider Middle Name:
RENNICK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RENNICK
Provider Other First Name:
KELLY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861757148
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7755 OFFICE PLAZA DR N
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
WEST DES MOINES
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
50266-2339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7755 OFFICE PLAZA DR N
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
WEST DES MOINES
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
50266-2339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
515-201-0439
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/11/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  06475 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1861757148 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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