Provider Demographics
NPI:1275607855
Name:MEAD, KELLY L (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:MEAD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:113 ELM ST STE 304
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3739
Mailing Address - Country:US
Mailing Address - Phone:860-741-2225
Mailing Address - Fax:860-741-2229
Practice Address - Street 1:113 ELM ST STE 304
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:860-741-2225
Practice Address - Fax:860-741-2229
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00332207N00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
S05717Medicare UPIN
R133762Medicare PIN