Basic Information
| Provider Information | |||||||||
| NPI: | 1497910814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAMLETTE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MEAGHER | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1860 PAYSPHERE CIRCLE | ||||||||
| Address2: | |||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304699200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 430 PENNSYLVANIA AVE STE 330 | ||||||||
| Address2: | |||||||||
| City: | GLEN ELLYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601374464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305457576 | ||||||||
| FaxNumber: | 6305457839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2008 | ||||||||
| LastUpdateDate: | 06/17/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 085003118 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 085003118 | 01 | PA LICENSE | OTHER |