Provider Demographics
NPI:1770977571
Name:KELLEY, AUDREY CHRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:CHRISTINE
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:CHRISTINE
Other - Last Name:BUTCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4015 LAKE OTIS PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5235
Mailing Address - Country:US
Mailing Address - Phone:907-206-8075
Mailing Address - Fax:907-206-8076
Practice Address - Street 1:4100 LAKE OTIS PKWY STE 216
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5230
Practice Address - Country:US
Practice Address - Phone:907-563-2873
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-19
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK113710363AS0400X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1667427Medicaid