Provider Demographics
NPI:1700844925
Name:PHELPS, KELLY L (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:PHELPS
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:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-529-0586
Practice Address - Street 1:117 E CLARK ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2702
Practice Address - Country:US
Practice Address - Phone:618-252-8625
Practice Address - Fax:618-252-2540
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S74772Medicare UPIN
IL214881Medicare Oscar/Certification
K18676Medicare ID - Type Unspecified