Provider Demographics
NPI:1679096424
Name:ORGAN, KELLIE MARIE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:MARIE
Last Name:ORGAN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:MARIE
Other - Last Name:HOLLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:3635 ST. JOHNS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205
Mailing Address - Country:US
Mailing Address - Phone:904-686-7525
Mailing Address - Fax:
Practice Address - Street 1:3635 ST. JOHNS AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205
Practice Address - Country:US
Practice Address - Phone:904-686-7525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110764363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant