Provider Demographics
NPI:1265628275
Name:KELLY, COURTNEY ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:COURTNEY
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:COURTNEY
Other - Middle Name:ANN
Other - Last Name:VERDEYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:1345 EDWARDS ST STE 2
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1692
Practice Address - Country:US
Practice Address - Phone:815-942-1421
Practice Address - Fax:815-488-2033
Is Sole Proprietor?:No
Enumeration Date:2007-09-24
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003055363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085.003055OtherIL LICENSE