Provider Demographics
NPI:1487193132
Name:KRIKLAVA, KELLY (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KRIKLAVA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-781-2799
Mailing Address - Fax:772-781-2716
Practice Address - Street 1:3333 BURNET AVE, ML 1013
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229
Practice Address - Country:US
Practice Address - Phone:513-636-4466
Practice Address - Fax:513-636-5846
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006386363A00000X
FLPA9111155363A00000X
TN4542363AS0400X
OH50.007959RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical