Provider Demographics
NPI:1427394345
Name:LAMB, KELLI MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:LAMB
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 1:1 SHIRCLIFF WAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204
Mailing Address - Country:US
Mailing Address - Phone:904-308-3960
Mailing Address - Fax:904-308-3533
Practice Address - Street 1:1200 RIVERPLACE BLVD
Practice Address - Street 2:SUITE 620
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-9046
Practice Address - Country:US
Practice Address - Phone:904-396-6620
Practice Address - Fax:904-396-6528
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-20
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant