Provider Demographics
NPI:1740378793
Name:AMENTA, KELLY C (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:AMENTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:C
Other - Last Name:HEATH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2315 MYRTLE ST STE 120
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-4602
Mailing Address - Country:US
Mailing Address - Phone:814-456-9197
Mailing Address - Fax:814-455-2765
Practice Address - Street 1:2315 MYRTLE ST STE 120
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-4602
Practice Address - Country:US
Practice Address - Phone:814-456-9197
Practice Address - Fax:814-455-2765
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051399363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P97993Medicare UPIN