Provider Demographics
NPI:1770885386
Name:WHOOLERY, KELLEY ALINA (PA-C)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:ALINA
Last Name:WHOOLERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:A
Other - Last Name:TRACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:509 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1310
Mailing Address - Country:US
Mailing Address - Phone:304-720-3555
Mailing Address - Fax:304-720-3556
Practice Address - Street 1:509 2ND AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1310
Practice Address - Country:US
Practice Address - Phone:304-720-3555
Practice Address - Fax:304-720-3556
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01441363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0206415000OtherGROUP MEDICAID
WV9328971OtherMEDICARE GROUP