Provider Demographics
NPI:1871117689
Name:KELLY, DEVIN WALTER (PA)
Entity type:Individual
Prefix:
First Name:DEVIN
Middle Name:WALTER
Last Name:KELLY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 UNIVERSITY BLVD S STE 415
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4299
Mailing Address - Country:US
Mailing Address - Phone:904-296-2522
Mailing Address - Fax:
Practice Address - Street 1:3627 UNIVERSITY BLVD S STE 415
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4299
Practice Address - Country:US
Practice Address - Phone:904-296-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113409363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty