Provider Demographics
NPI:1497219380
Name:PICKERING, KELLY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:PICKERING
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 1:9650 GROSS POINT RD STE 2900
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1214
Mailing Address - Country:US
Mailing Address - Phone:847-404-6162
Mailing Address - Fax:224-251-4568
Practice Address - Street 1:9650 GROSS POINT RD STE 2900
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:847-404-6162
Practice Address - Fax:224-251-4568
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant