Provider Demographics
NPI:1093881328
Name:KELLY, MARYANN (PA)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3300 ARAMINGO AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4500
Mailing Address - Country:US
Mailing Address - Phone:215-634-5110
Mailing Address - Fax:215-634-5108
Practice Address - Street 1:3300 ARAMINGO AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19134-4500
Practice Address - Country:US
Practice Address - Phone:215-634-5110
Practice Address - Fax:215-634-5108
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAPA1027531363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S56589Medicare UPIN