Provider Demographics
NPI:1114253309
Name:KELLY, CAITLIN MARIE
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3557 N MARSHFIELD AVE
Mailing Address - Street 2:2R
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-1287
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1755 WITTINGTON PL
Practice Address - Street 2:SUITE 800
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-1927
Practice Address - Country:US
Practice Address - Phone:214-442-4429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant