Provider Demographics
NPI:1861402315
Name:KELLOGG, AMY (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:KELLOGG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-595-2505
Mailing Address - Fax:508-854-0650
Practice Address - Street 1:630 PLANTATION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2038
Practice Address - Country:US
Practice Address - Phone:508-595-2505
Practice Address - Fax:508-854-0650
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD184767363A00000X
RIPA00738363A00000X
MAPA1870363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant