Provider Demographics
NPI:1447501226
Name:MUELLER, KELLIE MARIE (PA)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:MUELLER
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 1:1950 ROCKLEDGE BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3763
Mailing Address - Country:US
Mailing Address - Phone:321-636-0005
Mailing Address - Fax:
Practice Address - Street 1:1950 ROCKLEDGE BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3763
Practice Address - Country:US
Practice Address - Phone:321-636-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9106732363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical