Healthcare Provider Details

I. General information

NPI: 1184554230
Provider Name (Legal Business Name): TRACEY DAWN KELLY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W IRONWOOD DR STE 350
COEUR D ALENE ID
83814-4487
US

IV. Provider business mailing address

6840 N VERLAINE DR
COEUR D ALENE ID
83815-8110
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-5222
  • Fax:
Mailing address:
  • Phone: 208-215-5723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2881912
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: