Provider Demographics
NPI:1154396745
Name:BRAWLEY, KELLY J (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:BRAWLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 94670
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73143-4670
Mailing Address - Country:US
Mailing Address - Phone:847-382-6579
Mailing Address - Fax:847-382-7194
Practice Address - Street 1:120 N NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-3347
Practice Address - Country:US
Practice Address - Phone:847-382-6579
Practice Address - Fax:847-382-7194
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085-001816363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400288489Medicare PIN
ILP68093Medicare UPIN