Provider Demographics
NPI:1598741316
Name:DUNNE, KELLY M (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:DUNNE
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 1:2415 N ORANGE AVE STE 601
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5558
Mailing Address - Country:US
Mailing Address - Phone:407-303-2070
Mailing Address - Fax:
Practice Address - Street 1:2415 N ORANGE AVE STE 601
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5558
Practice Address - Country:US
Practice Address - Phone:407-303-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1223363A00000X
FLPA9103581363AM0700X, 363A00000X
AZ3352363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003104661AMedicaid
FL002051300Medicaid
FLPA9103581OtherMEDICAL LICENSE
GA003104661AMedicaid
Q61439Medicare UPIN