Provider Demographics
NPI:1942017298
Name:KELLY, MACKENZIE KATHLEEN
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:KATHLEEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132A VETERANS LN UNIT 117
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-3424
Mailing Address - Country:US
Mailing Address - Phone:215-806-5281
Mailing Address - Fax:
Practice Address - Street 1:1 CONVENTION AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4311
Practice Address - Country:US
Practice Address - Phone:215-662-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1218151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant