Provider Demographics
NPI:1306217211
Name:DEPRIEST, KELSEY WELSH (PA-C)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:WELSH
Last Name:DEPRIEST
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 1:82 NEW PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH FRANKLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06254-1807
Mailing Address - Country:US
Mailing Address - Phone:860-889-7345
Mailing Address - Fax:
Practice Address - Street 1:82 NEW PARK AVE
Practice Address - Street 2:
Practice Address - City:NORTH FRANKLIN
Practice Address - State:CT
Practice Address - Zip Code:06254-1807
Practice Address - Country:US
Practice Address - Phone:860-889-7345
Practice Address - Fax:860-885-7227
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001027363AS0400X
CT5417363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical