Provider Demographics
NPI:1497856314
Name:KELLY, JONNA M (PA-C)
Entity type:Individual
Prefix:
First Name:JONNA
Middle Name:M
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 1:21718 STERLING DR
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-8761
Mailing Address - Country:US
Mailing Address - Phone:360-707-1164
Mailing Address - Fax:
Practice Address - Street 1:2930 SQUALICUM PKWY
Practice Address - Street 2:101
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1854
Practice Address - Country:US
Practice Address - Phone:360-988-9008
Practice Address - Fax:360-594-4012
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004532363A00000X
HIAMD-431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAQ07037Medicare UPIN