Provider Demographics
NPI:1306436910
Name:STANLEY, KELLI M (PA-C)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:STANLEY
Suffix:
Gender:F
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:13011 S 104TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1508
Mailing Address - Country:US
Mailing Address - Phone:708-478-3600
Mailing Address - Fax:708-478-3552
Practice Address - Street 1:13011 S 104TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PALOS PARK
Practice Address - State:IL
Practice Address - Zip Code:60464-1508
Practice Address - Country:US
Practice Address - Phone:708-274-3278
Practice Address - Fax:708-274-3299
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2021-07-28
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
IL085008149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant