Provider Demographics
NPI:1134498132
Name:HEER, KELLI NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:NICOLE
Last Name:HEER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4464
Mailing Address - Country:US
Mailing Address - Phone:850-233-3376
Mailing Address - Fax:850-522-8354
Practice Address - Street 1:106 WESTSIDE DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1908
Practice Address - Country:US
Practice Address - Phone:877-231-3376
Practice Address - Fax:850-522-8354
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA 803363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPA.803OtherAL PHYSICIAN ASSISTANT