MEDICARE: MRS. MELANIE MERCEDES 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	2366	AZ

General Provider Information

NPI Number	:	1609090950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MELANIE MERCEDES KELLY PA-C

Provider Business Mailing Address
First Line	:	1633 W MANOR ST
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224-5104
Country	:	US
Telephone Number	:	480-855-8467
Fax Number	:	480-855-8471

Provider Business Practice Location Address
First Line	:	1455 W CHANDLER BLVD
Second Line	:	BUILDING A
City	:	CHANDLER
State	:	AZ
Zip	:	85224-6177
Country	:	US
Telephone Number	:	480-899-2900
Fax Number	:	480-899-0681

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

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	07/08/2007

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