Provider Demographics
NPI:1750830477
Name:KIDD, KELLY MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:KIDD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:KYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8450 NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-1381
Mailing Address - Country:US
Mailing Address - Phone:317-802-2000
Mailing Address - Fax:317-802-2170
Practice Address - Street 1:8450 NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1381
Practice Address - Country:US
Practice Address - Phone:317-802-2000
Practice Address - Fax:317-802-2170
Is Sole Proprietor?:No
Enumeration Date:2016-09-22
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002117A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant