Provider Demographics
NPI:1124676580
Name:BLEAKLEY, KELLY JO (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:BLEAKLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:494 MEAD ST SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-2023
Mailing Address - Country:US
Mailing Address - Phone:772-473-3320
Mailing Address - Fax:
Practice Address - Street 1:3636 33RD ST STE 306
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11106-2329
Practice Address - Country:US
Practice Address - Phone:844-403-4325
Practice Address - Fax:424-625-0010
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9269363A00000X
NY025755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant