Provider Demographics
NPI:1497181218
Name:KELLY, CHARMAINE MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CHARMAINE
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:72700 DINAH SHORE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-0859
Mailing Address - Country:US
Mailing Address - Phone:909-825-7084
Mailing Address - Fax:909-422-3002
Practice Address - Street 1:670 BOULEVARD DE FRANCE
Practice Address - Street 2:BRANCH HEALTH CLINIC
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29902-6122
Practice Address - Country:US
Practice Address - Phone:843-228-4237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53952363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant