Provider Demographics
NPI:1811993942
Name:KELLY, LYNN C (PA)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:5900 LAKE WRIGHT DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-1871
Mailing Address - Country:US
Mailing Address - Phone:757-213-5700
Mailing Address - Fax:757-213-5701
Practice Address - Street 1:1051 LOFTIS
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4250
Practice Address - Country:US
Practice Address - Phone:757-873-9400
Practice Address - Fax:757-873-9420
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2008-04-28
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Provider Licenses
StateLicense IDTaxonomies
VA0110001615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA76055POtherOPTIMA
VAP86689Medicare UPIN
VA007423V25Medicare PIN