Provider Demographics
NPI:1740481993
Name:LINDLEY, KELLY DEOMELLAS (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:DEOMELLAS
Last Name:LINDLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:C
Other - Last Name:DEORNELLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:210 EAST DERENNE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-5260
Practice Address - Street 1:340 EISENHOWER DRIVE
Practice Address - Street 2:SUITE 1200
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406
Practice Address - Country:US
Practice Address - Phone:912-443-4200
Practice Address - Fax:912-355-8124
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005062363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1553OtherTEMP PERMIT NUMBER
GA1078016OtherNCCPA
GA005062OtherLICENSE