Provider Demographics
NPI:1154634244
Name:STEVENSON, KELLY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:STEVENSON
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 1:804 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-2206
Mailing Address - Country:US
Mailing Address - Phone:308-455-3600
Mailing Address - Fax:308-455-3950
Practice Address - Street 1:804 22ND AVE
Practice Address - Street 2:
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-2206
Practice Address - Country:US
Practice Address - Phone:308-455-3600
Practice Address - Fax:308-455-3950
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1535363A00000X
KS15-01496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant