Provider Demographics
NPI:1548756182
Name:LEDDY, KELLY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:LEDDY
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 1:146 TENNIS CT
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9433
Mailing Address - Country:US
Mailing Address - Phone:732-575-6554
Mailing Address - Fax:
Practice Address - Street 1:2315 NJ 34
Practice Address - Street 2:
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736
Practice Address - Country:US
Practice Address - Phone:732-974-0404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00480700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant