Basic Information
| Provider Information | |||||||||
| NPI: | 1972236446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | KENDRA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 PATTERSON RD APT 1 | ||||||||
| Address2: | |||||||||
| City: | HAMPDEN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044442000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078525931 | ||||||||
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| Practice Location | |||||||||
| Address1: | 489 STATE ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079737000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2022 | ||||||||
| LastUpdateDate: | 08/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.