Healthcare Provider Details

I. General information

NPI: 1982656674
Provider Name (Legal Business Name): AMBER LEE KELLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

954 N SAMUEL MOORE PKWY STE C
MOORESVILLE IN
46158-1475
US

IV. Provider business mailing address

801 YORK ST
MANITOWOC WI
54220-4630
US

V. Phone/Fax

Practice location:
  • Phone: 317-834-5466
  • Fax: 317-584-3794
Mailing address:
  • Phone: 920-663-9008
  • Fax: 920-684-1439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10000324A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: