Provider Demographics
NPI:1275144180
Name:DECARLO, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:DECARLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 NEXUS DR STE NW2-100
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19803-3000
Mailing Address - Country:US
Mailing Address - Phone:302-623-2597
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 5A43
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2130
Practice Address - Country:US
Practice Address - Phone:302-623-0188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical