Provider Demographics
NPI:1477333763
Name:AGALSOFF, KELLIE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:AGALSOFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:MARIE
Other - Last Name:REDONDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:310 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-3407
Mailing Address - Country:US
Mailing Address - Phone:256-617-1354
Mailing Address - Fax:
Practice Address - Street 1:310 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-3407
Practice Address - Country:US
Practice Address - Phone:256-617-1354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-03
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant