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General NPI Number Information
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NPI Number | 1568695799
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Entity Type | Individual
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Provider Name | COLLEEN E KELLY PA
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Gender | Female
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Dates
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Enumeration Date | 09/04/2009
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Last Update Date | 12/20/2022
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Provider Practice Location Address
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Address Line | 319 E MADISON ST FL 2
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City | SPRINGFIELD
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State | IL
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Zip | 62701-1035
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Country | US
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Telephone | 217-545-8000
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Fax | 217-545-9537
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Provider Business Mailing Address
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Address Line | 201 E MADISON ST STE 328
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City | SPRINGFIELD
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State | IL
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Zip | 62702-5131
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Country | US
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Telephone | 217-545-8000
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085003555
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License Number State | IL
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