Provider Demographics
NPI:1225495526
Name:MULLIKIN, KELLY MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:MULLIKIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:EGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2939 ALT 19 # MS 702
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-1928
Mailing Address - Country:US
Mailing Address - Phone:727-786-5058
Mailing Address - Fax:813-635-2639
Practice Address - Street 1:2939 ALT 19 # MS 702
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-1928
Practice Address - Country:US
Practice Address - Phone:727-786-5058
Practice Address - Fax:813-635-2639
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109308363A00000X, 363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108346500Medicaid