Provider Demographics
NPI:1760798052
Name:FAILLO, KELLY KATHLEEN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:KATHLEEN
Last Name:FAILLO
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 1:500 THOMAS MORE PKWY
Mailing Address - Street 2:STE 200
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3454
Mailing Address - Country:US
Mailing Address - Phone:859-341-4842
Mailing Address - Fax:
Practice Address - Street 1:500 THOMAS MORE PKWY
Practice Address - Street 2:STE 200
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3454
Practice Address - Country:US
Practice Address - Phone:859-341-4842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105470363A00000X
KY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant