Provider Demographics
NPI:1184035735
Name:BRIGHAM, KELLY JO (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:JO
Last Name:BRIGHAM
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 1:528 NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-2366
Mailing Address - Country:US
Mailing Address - Phone:508-675-2266
Mailing Address - Fax:
Practice Address - Street 1:528 NEWTON ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-2366
Practice Address - Country:US
Practice Address - Phone:508-675-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-16
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant