Basic Information
| Provider Information | |||||||||
| NPI: | 1487193132 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRIKLAVA | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349950417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7727812799 | ||||||||
| FaxNumber: | 7727812716 | ||||||||
| Practice Location | |||||||||
| Address1: | 880 MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381033409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015457222 | ||||||||
| FaxNumber: | 9015458292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2017 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C0006386 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA9111155 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 4542 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.