Healthcare Provider Details

I. General information

NPI: 1306436910
Provider Name (Legal Business Name): KELLI M STANLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13011 S 104TH AVE STE 100
PALOS PARK IL
60464-1508
US

IV. Provider business mailing address

13011 S 104TH AVE STE 100
PALOS PARK IL
60464-1508
US

V. Phone/Fax

Practice location:
  • Phone: 708-274-3278
  • Fax: 708-274-3299
Mailing address:
  • Phone: 708-478-3600
  • Fax: 708-478-3552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008149
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: