Provider Demographics
NPI:1902859085
Name:MACELLAIO, KRISTY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:
Last Name:MACELLAIO
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 1:1256 WATERFORD DR STE 230
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-4511
Mailing Address - Country:US
Mailing Address - Phone:630-499-2404
Mailing Address - Fax:630-692-5518
Practice Address - Street 1:2121 RIDGE AVE STE 101
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7001
Practice Address - Country:US
Practice Address - Phone:630-820-7100
Practice Address - Fax:630-264-2524
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL385000877363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant