Provider Demographics
NPI:1477504595
Name:POWELL, KELLY JO (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JO
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:J
Other - Last Name:OSBORNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-6200
Mailing Address - Fax:859-258-6203
Practice Address - Street 1:3085 LAKECREST CIR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1707
Practice Address - Country:US
Practice Address - Phone:859-258-8600
Practice Address - Fax:859-258-8610
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA942363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant