Provider Demographics
NPI:1861722852
Name:BREZOVIC, KELLI CHARLENE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:CHARLENE
Last Name:BREZOVIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:2470 PRUDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4206
Mailing Address - Country:US
Mailing Address - Phone:757-539-1503
Mailing Address - Fax:757-539-0107
Practice Address - Street 1:2470 PRUDEN BLVD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4206
Practice Address - Country:US
Practice Address - Phone:757-539-1503
Practice Address - Fax:757-539-0107
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002465363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical