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General NPI Number Information
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NPI Number | 1417059296
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Entity Type | Individual
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Provider Name | COLLEEN ELIZABETH KELLY MPAS,PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/02/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5000 W NATIONAL AVE
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City | MILWAUKEE
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State | WI
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Zip | 53295-0001
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Country | US
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Telephone | 414-384-2000
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Fax | 414-389-4134
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Provider Business Mailing Address
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Address Line | 65 E FIELDSTONE CIR APT 2
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City | OAK CREEK
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State | WI
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Zip | 53154-2185
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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