Provider Demographics
NPI:1083135610
Name:KELLY, KELSEY MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:MARIE
Other - Last Name:LANGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:
Mailing Address - City:DALE
Mailing Address - State:IN
Mailing Address - Zip Code:47523-0599
Mailing Address - Country:US
Mailing Address - Phone:812-937-7140
Mailing Address - Fax:
Practice Address - Street 1:4 W VINE ST
Practice Address - Street 2:
Practice Address - City:DALE
Practice Address - State:IN
Practice Address - Zip Code:47523-9061
Practice Address - Country:US
Practice Address - Phone:812-937-7140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002285A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical