Provider Demographics
NPI:1437663366
Name:MARCHEWKA, KELLI JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JEAN
Last Name:MARCHEWKA
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 1:2722 PARK ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-8209
Mailing Address - Country:US
Mailing Address - Phone:407-312-8838
Mailing Address - Fax:
Practice Address - Street 1:598 STERTHAUS DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5128
Practice Address - Country:US
Practice Address - Phone:386-256-2565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant