Provider Demographics
NPI:1124274378
Name:WAY, KELLY JEAN (BS, MS, PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEAN
Last Name:WAY
Suffix:
Gender:F
Credentials:BS, MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34B SPRINGBROOK RD
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-1001
Mailing Address - Country:US
Mailing Address - Phone:401-348-8565
Mailing Address - Fax:
Practice Address - Street 1:326 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2740
Practice Address - Country:US
Practice Address - Phone:860-889-8331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002126363AM0700X
RIPA00473363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical