Provider Demographics
NPI:1386768992
Name:OWENS, KELLY A (PA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:A
Last Name:OWENS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:1247 RICKERT DRIVE
Practice Address - Street 2:#200
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540
Practice Address - Country:US
Practice Address - Phone:630-420-2323
Practice Address - Fax:630-420-2323
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85-002264363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-002264OtherPHYSICIAN ASSISTANTS LICE