Provider Demographics
NPI:1609681105
Name:KELLY, TAYLOR GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:GRACE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 WITHERBY LN
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-4477
Mailing Address - Country:US
Mailing Address - Phone:678-882-6664
Mailing Address - Fax:
Practice Address - Street 1:5252 W UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-7822
Practice Address - Country:US
Practice Address - Phone:469-764-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-11
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18594363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant