Provider Demographics
NPI:1780031625
Name:GRAHAM, KELLY ANN (PA-C, PTA)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:PA-C, PTA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1222 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1215
Mailing Address - Country:US
Mailing Address - Phone:321-841-6444
Mailing Address - Fax:407-650-1307
Practice Address - Street 1:1222 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:321-841-6444
Practice Address - Fax:407-650-1307
Is Sole Proprietor?:No
Enumeration Date:2016-05-20
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26641225200000X
FL9112573363A00000X
FLPA112573363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104300400Medicaid