Basic Information
| Provider Information | |||||||||
| NPI: | 1578983433 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORDHAM | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAY | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 CAHABA RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN BRK | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352231937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058779773 | ||||||||
| FaxNumber: | 2058779775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2014 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.961 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.