Provider Demographics
NPI:1821413329
Name:STANEK, KELLY JEAN-MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN-MARIE
Last Name:STANEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN-MARIE
Other - Last Name:HERMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10330 S ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1971
Mailing Address - Country:US
Mailing Address - Phone:708-237-7200
Mailing Address - Fax:708-237-7201
Practice Address - Street 1:10330 S ROBERTS RD
Practice Address - Street 2:
Practice Address - City:PALOS HILLS
Practice Address - State:IL
Practice Address - Zip Code:60465-1971
Practice Address - Country:US
Practice Address - Phone:708-237-7252
Practice Address - Fax:708-237-7201
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.004943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant