Provider Demographics
NPI:1679903819
Name:HUMES, KELLY BRIANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BRIANNE
Last Name:HUMES
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 1:174 PERCIVAL AVE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2033
Mailing Address - Country:US
Mailing Address - Phone:860-402-0285
Mailing Address - Fax:
Practice Address - Street 1:1200 N. ELM STREET
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27404-0467
Practice Address - Country:US
Practice Address - Phone:336-207-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-26
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant