MEDICARE: MRS. KELSEY MARIE KELLY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	10002285A	IN

General Provider Information

NPI Number	:	1083135610
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELSEY MARIE KELLY PA-C

Provider Business Mailing Address
First Line	:	PO BOX 599
Second Line	:
City	:	DALE
State	:	IN
Zip	:	47523-0599
Country	:	US
Telephone Number	:	812-937-7140
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 W VINE ST
Second Line	:
City	:	DALE
State	:	IN
Zip	:	47523-9061
Country	:	US
Telephone Number	:	812-937-7140
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2017
Last Update Date	:	03/17/2018

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