Provider Demographics
NPI:1578836219
Name:CHAMPION, KELLY NICOLE (MPAS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:NICOLE
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:CHAMPION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:26 FRANKFORT ST # 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-3114
Mailing Address - Country:US
Mailing Address - Phone:978-697-8726
Mailing Address - Fax:
Practice Address - Street 1:199 REEDSDALE RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-3926
Practice Address - Country:US
Practice Address - Phone:617-696-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant