Provider Demographics
NPI:1154368389
Name:LANDRY, KELLY CELESTE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:CELESTE
Last Name:LANDRY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:CELESTE
Other - Last Name:MONDELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5501 ABERCORN STREET
Mailing Address - Street 2:STE D BOX 104
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405
Mailing Address - Country:US
Mailing Address - Phone:912-232-9700
Mailing Address - Fax:912-748-0270
Practice Address - Street 1:5353 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6015
Practice Address - Country:US
Practice Address - Phone:912-232-9700
Practice Address - Fax:912-748-0270
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11526363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1529095Medicaid
LA5C060PD18Medicare PIN
Q23097Medicare UPIN