Provider Demographics
NPI:1881664902
Name:KELLY, MAUREEN C (PA)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3730
Mailing Address - Country:US
Mailing Address - Phone:203-488-6358
Mailing Address - Fax:203-481-5327
Practice Address - Street 1:960 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3730
Practice Address - Country:US
Practice Address - Phone:203-488-6358
Practice Address - Fax:203-481-5327
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001363363A00000X
CT1363363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT290001363CT02OtherANTHEM BCBS
CT004245272Medicaid
CT004245272Medicaid
CT290001363CT02OtherANTHEM BCBS