Provider Demographics
NPI:1063469385
Name:THRUSH, KELLY L (CRNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:THRUSH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:500 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2360
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:35 HOPE DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2086
Practice Address - Country:US
Practice Address - Phone:717-531-5160
Practice Address - Fax:717-531-2034
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008173363L00000X
IL209008862363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q47300Medicare UPIN
PA092517Medicare PIN