Provider Demographics
NPI:1669032025
Name:OWENS, KELLY CAMPBELL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:CAMPBELL
Last Name:OWENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:CAMPBELL
Other - Last Name:HODILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1174
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-1174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:730 MALABAR RD STE B
Practice Address - Street 2:
Practice Address - City:MALABAR
Practice Address - State:FL
Practice Address - Zip Code:32950-3140
Practice Address - Country:US
Practice Address - Phone:407-200-9258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111980363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant