Provider Demographics
NPI:1881002517
Name:PHELAN, KERRY MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:MARIE
Last Name:PHELAN
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 1:91 VOLUNTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PAWCATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06379-1366
Mailing Address - Country:US
Mailing Address - Phone:860-599-5477
Mailing Address - Fax:860-599-5676
Practice Address - Street 1:91 VOLUNTOWN RD
Practice Address - Street 2:
Practice Address - City:PAWCATUCK
Practice Address - State:CT
Practice Address - Zip Code:06379-1366
Practice Address - Country:US
Practice Address - Phone:860-599-5477
Practice Address - Fax:860-599-5676
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant