Provider Demographics
NPI:1881218360
Name:CHAPMAN, KELLYN O'BRADY (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLYN
Middle Name:O'BRADY
Last Name:CHAPMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLYN
Other - Middle Name:PATRICIA
Other - Last Name:O'BRADY-CHAPMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:36622 FIVE MILE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48154-1900
Mailing Address - Country:US
Mailing Address - Phone:734-542-0200
Mailing Address - Fax:
Practice Address - Street 1:36622 FIVE MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1900
Practice Address - Country:US
Practice Address - Phone:734-542-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009920363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant