Provider Demographics
NPI:1982656674
Name:KELLEY, AMBER LEE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:AMBER
Middle Name:LEE
Last Name:KELLEY
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:954 N SAMUEL MOORE PKWY STE C
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1475
Practice Address - Country:US
Practice Address - Phone:317-834-5466
Practice Address - Fax:317-584-3794
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000324A363A00000X, 363A00000X
IL385.002286363A00000X
FLPA9106612363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS78979Medicare UPIN