Provider Demographics
NPI:1326411125
Name:BANE, KELLY A (PA-C, MPH)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:BANE
Suffix:
Gender:F
Credentials:PA-C, MPH
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:ALBRITTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1541 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4615
Mailing Address - Country:US
Mailing Address - Phone:850-431-7816
Mailing Address - Fax:
Practice Address - Street 1:1541 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4615
Practice Address - Country:US
Practice Address - Phone:850-431-7816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9111645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant