Provider Demographics
NPI:1295045474
Name:MACCONNELL, KALY R (PA-C)
Entity type:Individual
Prefix:
First Name:KALY
Middle Name:R
Last Name:MACCONNELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KALY
Other - Middle Name:R
Other - Last Name:LUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1709 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446-1115
Mailing Address - Country:US
Mailing Address - Phone:215-362-5555
Mailing Address - Fax:215-362-6353
Practice Address - Street 1:1709 N BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-1115
Practice Address - Country:US
Practice Address - Phone:215-362-5555
Practice Address - Fax:215-362-6353
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002538363A00000X
PAMA054607363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant