Provider Demographics
NPI:1003427618
Name:CROW, KELLY JAN (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JAN
Last Name:CROW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2705
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-2705
Mailing Address - Country:US
Mailing Address - Phone:256-801-6048
Mailing Address - Fax:256-801-6218
Practice Address - Street 1:401 LOWELL DR SE STE 1
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3738
Practice Address - Country:US
Practice Address - Phone:256-265-4462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant