Provider Demographics
NPI:1225038086
Name:RICHARDSON, KELLY R (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:R
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:914 N DIXIE AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2520
Mailing Address - Country:US
Mailing Address - Phone:270-769-1049
Mailing Address - Fax:270-735-1978
Practice Address - Street 1:800 ZORN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1433
Practice Address - Country:US
Practice Address - Phone:029-563-4525
Practice Address - Fax:270-735-1978
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
KYPA816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95004131Medicaid
KY95004131Medicaid
KY0785303Medicare ID - Type Unspecified