Provider Demographics
NPI:1376297564
Name:KELLEHER, CARLY (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:KELLEHER
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:2051 PLAINFIELD RD
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1865
Practice Address - Country:US
Practice Address - Phone:815-741-4343
Practice Address - Fax:815-741-8660
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant