Provider Demographics
NPI:1063471175
Name:WOOLLEY, KELLY (PAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WOOLLEY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CRANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:5228 W PLANO PKWY
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5005
Mailing Address - Country:US
Mailing Address - Phone:972-250-5700
Mailing Address - Fax:
Practice Address - Street 1:5228 W PLANO PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5005
Practice Address - Country:US
Practice Address - Phone:972-250-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX03901363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q24075Medicare UPIN
TX8C2512Medicare ID - Type Unspecified