Provider Demographics
NPI:1558899237
Name:KELLY, ELLEN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MARIE
Last Name:KELLY
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 1:3373 COMMERCE PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-7130
Mailing Address - Country:US
Mailing Address - Phone:330-804-9712
Mailing Address - Fax:330-804-9811
Practice Address - Street 1:3373 COMMERCE PKWY STE 2
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-7130
Practice Address - Country:US
Practice Address - Phone:330-804-9712
Practice Address - Fax:330-804-9811
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH363AS0400X
OH50.005148RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0234386Medicaid