Provider Demographics
NPI:1730453911
Name:NEELY, JENNIFER ALISSA (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ALISSA
Last Name:NEELY
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 1:2110 LEITER RD
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3660
Mailing Address - Country:US
Mailing Address - Phone:937-384-4841
Mailing Address - Fax:937-522-7626
Practice Address - Street 1:3535 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1221
Practice Address - Country:US
Practice Address - Phone:937-395-8646
Practice Address - Fax:937-395-8697
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50003466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH077350Medicare PIN