Provider Demographics
NPI:1003456286
Name:MAMEDE, KELLEY (PA)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:MAMEDE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 BUR REED RD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-3676
Mailing Address - Country:US
Mailing Address - Phone:330-620-9432
Mailing Address - Fax:
Practice Address - Street 1:402 S STATE ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-5000
Practice Address - Country:US
Practice Address - Phone:740-387-0650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant