Provider Demographics
NPI:1578999322
Name:KELLY, STEPHANIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:BRONSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:51 NATHAN DR
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-1317
Mailing Address - Country:US
Mailing Address - Phone:631-767-0015
Mailing Address - Fax:
Practice Address - Street 1:1300 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2031
Practice Address - Country:US
Practice Address - Phone:631-549-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23017034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant