Provider Demographics
NPI:1558889410
Name:KELLEY, KATELYN MAE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:MAE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:MAE
Other - Last Name:GERSTENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4776 HODGES BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-7218
Mailing Address - Country:US
Mailing Address - Phone:904-404-8555
Mailing Address - Fax:904-517-1619
Practice Address - Street 1:4776 HODGES BLVD STE 105
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-7218
Practice Address - Country:US
Practice Address - Phone:904-404-8555
Practice Address - Fax:904-517-1619
Is Sole Proprietor?:No
Enumeration Date:2017-08-31
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant