Healthcare Provider Details

I. General information

NPI: 1619095270
Provider Name (Legal Business Name): KELLY MARTI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 STATE HIGHWAY 248 STE 200
BRANSON MO
65616-4186
US

IV. Provider business mailing address

PO BOX 802843
KANSAS CITY MO
64180-2843
US

V. Phone/Fax

Practice location:
  • Phone: 417-336-4112
  • Fax: 417-335-4684
Mailing address:
  • Phone: 417-730-6430
  • Fax: 417-269-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2014023983
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: