Provider Demographics
NPI:1306434600
Name:KELLY, MEGHAN (PA)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 SCHOOLHOUSE DR
Mailing Address - Street 2:UNIT 405
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06110-1438
Mailing Address - Country:US
Mailing Address - Phone:860-371-8683
Mailing Address - Fax:
Practice Address - Street 1:13 CHURCH RD
Practice Address - Street 2:
Practice Address - City:EAST GRANBY
Practice Address - State:CT
Practice Address - Zip Code:06026-9406
Practice Address - Country:US
Practice Address - Phone:860-653-4526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant