Provider Demographics
NPI:1700815958
Name:AXTELL-KELLY, CARYN JOY (PA-C)
Entity Type:Individual
Prefix:
First Name:CARYN
Middle Name:JOY
Last Name:AXTELL-KELLY
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:PO BOX 2492
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-2492
Mailing Address - Country:US
Mailing Address - Phone:909-591-0843
Mailing Address - Fax:909-591-7226
Practice Address - Street 1:13193 CENTRAL AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710
Practice Address - Country:US
Practice Address - Phone:909-591-0843
Practice Address - Fax:909-591-7226
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17278363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17278Medicaid
CAP00417678Medicare PIN
CA0PA172780Medicare PIN
CA0PA172780Medicare ID - Type Unspecified