MEDICARE: ERIN KELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1780579862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERIN KELLY

Provider Business Mailing Address
First Line	:	106 DENTON RD
Second Line	:
City	:	MADISONVILLE
State	:	TN
Zip	:	37354-7807
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	779 MEETING ST UNIT A
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29403-3121
Country	:	US
Telephone Number	:	720-308-7022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2025
Last Update Date	:	06/10/2025

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Directions to “ ERIN KELLY ” Practice Location

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