Provider Demographics
NPI:1962159756
Name:KELLY, LAUREN MICHELLE (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MICHELLE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 STAPLES AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-7323
Mailing Address - Country:US
Mailing Address - Phone:401-524-3347
Mailing Address - Fax:
Practice Address - Street 1:5750 POST RD STE 2B
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-2139
Practice Address - Country:US
Practice Address - Phone:401-885-5193
Practice Address - Fax:401-885-1466
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant