Provider Demographics
NPI:1639449697
Name:PASSARELLO, KELLY G (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:G
Last Name:PASSARELLO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:GLEFFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 602108
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:87 SPRINGVIEW LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-9077
Practice Address - Country:US
Practice Address - Phone:843-876-7979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-09
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08170363A00000X
SC1710207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8099NCOtherBCBS
TX320981901Medicaid
TX282534YKQHMedicare PIN