Provider Demographics
NPI:1487623799
Name:BRADY, KELLEE K (PA-C)
Entity type:Individual
Prefix:
First Name:KELLEE
Middle Name:K
Last Name:BRADY
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 347
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32004-0347
Mailing Address - Country:US
Mailing Address - Phone:253-888-9077
Mailing Address - Fax:253-888-9077
Practice Address - Street 1:413 LILLY RD SE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2108
Practice Address - Country:US
Practice Address - Phone:253-888-9077
Practice Address - Fax:904-634-0203
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003729363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9104257OtherFLORIDA LICENSE
WA200151OtherSTATE WRKS COMPENSATION
WA7314BROtherREGENCE BLUE SHIELD
WA8433237Medicaid
WA7314BROtherREGENCE BLUE SHIELD
WA8805673Medicare ID - Type Unspecified