Provider Demographics
NPI:1851628002
Name:EVANS, KELLY NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:EVANS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:LEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:250 CETRONIA RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-9147
Mailing Address - Country:US
Mailing Address - Phone:610-973-6200
Mailing Address - Fax:866-644-0894
Practice Address - Street 1:250 CETRONIA RD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-9147
Practice Address - Country:US
Practice Address - Phone:610-973-6200
Practice Address - Fax:866-644-0894
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057361363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical