MEDICARE: MRS. CHARMAINE 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	363A00000X	Physician Assistant	53952	CA

General Provider Information

NPI Number	:	1497181218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHARMAINE MARIE KELLY PA-C

Provider Business Mailing Address
First Line	:	72700 DINAH SHORE DR STE 200
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92211-0859
Country	:	US
Telephone Number	:	909-825-7084
Fax Number	:	909-422-3002

Provider Business Practice Location Address
First Line	:	670 BOULEVARD DE FRANCE
Second Line	:	BRANCH HEALTH CLINIC
City	:	PORT ROYAL
State	:	SC
Zip	:	29902-6122
Country	:	US
Telephone Number	:	843-228-4237
Fax Number	:

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

Provider Enumeration Date	:	09/25/2013
Last Update Date	:	03/24/2025

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