Provider Demographics
NPI:1982208609
Name:KELLEY, SARAH (PA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:KELLEY
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 1:730 S CLARK ST APT 505
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-1746
Mailing Address - Country:US
Mailing Address - Phone:513-609-2850
Mailing Address - Fax:
Practice Address - Street 1:1111 W DIVERSEY PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1318
Practice Address - Country:US
Practice Address - Phone:773-270-5600
Practice Address - Fax:773-360-7378
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant