Provider Demographics
NPI:1366476004
Name:LIME, KELLY (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LIME
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:OSGOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:19636 N 27TH AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-4013
Mailing Address - Country:US
Mailing Address - Phone:623-780-1999
Mailing Address - Fax:623-516-0950
Practice Address - Street 1:19636 N 27TH AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4013
Practice Address - Country:US
Practice Address - Phone:623-780-1999
Practice Address - Fax:623-516-0950
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2701363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P68794Medicare UPIN
AZ75291Medicare ID - Type Unspecified