Provider Demographics
NPI:1609090950
Name:KELLY, MELANIE MERCEDES (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:MERCEDES
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 1:1633 W MANOR ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5104
Mailing Address - Country:US
Mailing Address - Phone:480-855-8467
Mailing Address - Fax:480-855-8471
Practice Address - Street 1:1455 W CHANDLER BLVD
Practice Address - Street 2:BUILDING A
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-6177
Practice Address - Country:US
Practice Address - Phone:480-899-2900
Practice Address - Fax:480-899-0681
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2366363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant