Basic Information
| Provider Information | |||||||||
| NPI: | 1376184614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | DANA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8000 SR 64 E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342125001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417921404 | ||||||||
| FaxNumber: | 9417610712 | ||||||||
| Practice Location | |||||||||
| Address1: | 8000 SR 64 E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342125001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417921404 | ||||||||
| FaxNumber: | 9417610712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2019 | ||||||||
| LastUpdateDate: | 06/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9116042 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.