Provider Demographics
NPI:1831148220
Name:DURHAM, KELLY M (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:M
Last Name:DURHAM
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4021 BALMORAL DR SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6403
Mailing Address - Country:US
Mailing Address - Phone:256-539-2741
Mailing Address - Fax:256-539-2775
Practice Address - Street 1:4021 BALMORAL DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6403
Practice Address - Country:US
Practice Address - Phone:256-539-2741
Practice Address - Fax:256-539-2775
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51531165OtherBC BS
AL051556775000Medicare ID - Type Unspecified
AL51531165OtherBC BS