Provider Demographics
NPI:1366853889
Name:CAMACHO, KELLIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11924 FOREST HILL BLVD STE 10A-411
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6256
Mailing Address - Country:US
Mailing Address - Phone:305-403-1181
Mailing Address - Fax:305-403-1230
Practice Address - Street 1:3275 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-7251
Practice Address - Country:US
Practice Address - Phone:305-461-2000
Practice Address - Fax:786-228-4035
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-19
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9107864363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical