Provider Demographics
NPI:1093190514
Name:PORCHE, KELLY MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:PORCHE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:TRONCOSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2795 ROXBURGH DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2450
Mailing Address - Country:US
Mailing Address - Phone:678-230-4571
Mailing Address - Fax:
Practice Address - Street 1:2701 N DECATUR RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-5918
Practice Address - Country:US
Practice Address - Phone:678-230-4571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8252363A00000X
PAMA057719363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical