Provider Demographics
NPI:1669064945
Name:KELLY, AMANDA CATHERINE (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:CATHERINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:CATHERINE
Other - Last Name:MOSES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:606-330-7825
Practice Address - Street 1:740 S LIMESTONE STE B101
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-1140
Practice Address - Country:US
Practice Address - Phone:859-323-5661
Practice Address - Fax:859-323-6411
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2743363AM0700X, 363AS0400X, 363A00000X
KYTC016363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100636790Medicaid