Basic Information
| Provider Information | |||||||||
| NPI: | 1487623799 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADY | ||||||||
| FirstName: | KELLEE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 211492 | ||||||||
| Address2: | |||||||||
| City: | ROYAL PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334211492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3208069222 | ||||||||
| FaxNumber: | 8888829097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1503 OAK ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322043910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046340203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA10003729 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA10003729 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA9104257 | 01 | FL | FLORIDA LICENSE | OTHER | 200151 | 01 | WA | STATE WRKS COMPENSATION | OTHER | 7314BR | 01 | WA | REGENCE BLUE SHIELD | OTHER | 8433237 | 05 | WA | MEDICAID |