Individual
MRS. KELLY LEIGH MACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
995 N. PRINCE FREDERICK BLVD, SUITE 204, PRINCE FREDERICK, MD 20678
(410) 535-5855
(410) 535-6574
Mailing address
4505 KINGWOOD DR, STE 185, KINGWOOD, TX 77345-2618
(281) 747-5533
(281) 747-5534
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA07662
TX
363AM0700X
Medical Physician Assistant
PA18061
CA
Other
Enumeration date
12/01/2006
Last updated
08/13/2019
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