Provider Demographics
NPI:1225409394
Name:KELLY, MAURA KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:MAURA
Middle Name:KATHLEEN
Last Name:KELLY
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 1:500 BROOKLINE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5417
Mailing Address - Country:US
Mailing Address - Phone:617-732-4838
Mailing Address - Fax:
Practice Address - Street 1:500 BROOKLINE AVE
Practice Address - Street 2:SUITE E
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5417
Practice Address - Country:US
Practice Address - Phone:617-732-4838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5448363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant