Provider Demographics
NPI:1609553262
Name:KELLY, MIRANDA
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CHASE RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-6200
Mailing Address - Country:US
Mailing Address - Phone:609-668-4097
Mailing Address - Fax:
Practice Address - Street 1:600 S 43RD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4418
Practice Address - Country:US
Practice Address - Phone:215-596-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant