Provider Demographics
NPI:1396813960
Name:MACK, KELLY LEIGH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LEIGH
Last Name:MACK
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 1:4505 KINGWOOD DR
Mailing Address - Street 2:STE 185
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77345-2618
Mailing Address - Country:US
Mailing Address - Phone:281-747-5533
Mailing Address - Fax:281-747-5534
Practice Address - Street 1:995 N. PRINCE FREDERICK BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678
Practice Address - Country:US
Practice Address - Phone:410-535-5855
Practice Address - Fax:410-535-6574
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18061363AM0700X
TXPA07662363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical