Healthcare Provider Details

I. General information

NPI: 1043078041
Provider Name (Legal Business Name): GINA KELLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 N MAIN STREET EXT # 2
WALLINGFORD CT
06492-2400
US

IV. Provider business mailing address

65 QUARRY VILLAGE RD
CHESHIRE CT
06410-2062
US

V. Phone/Fax

Practice location:
  • Phone: 203-886-0036
  • Fax:
Mailing address:
  • Phone: 413-454-8706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number6510
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: