Provider Demographics
NPI:1184134140
Name:MILLICAN, KELLI FORSYTH (PA-C)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:FORSYTH
Last Name:MILLICAN
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: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:630-469-2000
Mailing Address - Fax:
Practice Address - Street 1:100 SPALDING DR STE 300
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6553
Practice Address - Country:US
Practice Address - Phone:630-790-1872
Practice Address - Fax:630-355-2515
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
085006375363AM0700X
IL085006375363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical