Provider Demographics
NPI:1043648116
Name:HART, KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 FINANCIAL DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701
Mailing Address - Country:US
Mailing Address - Phone:270-769-0110
Mailing Address - Fax:270-765-6953
Practice Address - Street 1:103 FINANCIAL DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701
Practice Address - Country:US
Practice Address - Phone:270-769-0110
Practice Address - Fax:270-765-6953
Is Sole Proprietor?:No
Enumeration Date:2013-10-28
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC241363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant