Provider Demographics
NPI:1528558830
Name:HUTH, KELLI MEGAN NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MEGAN NICOLE
Last Name:HUTH
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 1:43 WHITING HILL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:655 MAIN ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1699
Practice Address - Country:US
Practice Address - Phone:207-294-5600
Practice Address - Fax:207-294-3565
Is Sole Proprietor?:No
Enumeration Date:2018-05-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4114363AM0700X
MEPA2043363AS0400X
PA2043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical