Provider Demographics
NPI:1083234694
Name:CHRISTEL, KELLIE (PA-C)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:CHRISTEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:KURT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1384 BRIARCLIFFE BLVD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60189-7730
Mailing Address - Country:US
Mailing Address - Phone:630-802-1392
Mailing Address - Fax:
Practice Address - Street 1:1384 BRIARCLIFFE BLVD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-7730
Practice Address - Country:US
Practice Address - Phone:630-802-1392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085008269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant