Provider Demographics
NPI:1255595708
Name:LONDON, KELLY RAE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:RAE
Last Name:LONDON
Suffix:
Gender:F
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:1241 PARKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTE
Mailing Address - State:PA
Mailing Address - Zip Code:16823-2520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-9800
Practice Address - Country:US
Practice Address - Phone:570-214-4777
Practice Address - Fax:570-271-7158
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA053465363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical