Provider Demographics
NPI:1568912509
Name:KELLY, STEPHANIE WOESTE (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:WOESTE
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 1:16105 S LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5503
Mailing Address - Country:US
Mailing Address - Phone:708-636-3767
Mailing Address - Fax:708-636-4361
Practice Address - Street 1:16105 S LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5503
Practice Address - Country:US
Practice Address - Phone:708-636-3767
Practice Address - Fax:708-636-4361
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical