Provider Demographics
NPI:1093099814
Name:KELLY, SUSANNE MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:SUSANNE
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 AURORA AVE
Mailing Address - Street 2:
Mailing Address - City:GIRARD
Mailing Address - State:PA
Mailing Address - Zip Code:16417-1241
Mailing Address - Country:US
Mailing Address - Phone:814-460-1464
Mailing Address - Fax:
Practice Address - Street 1:907 AURORA AVE
Practice Address - Street 2:
Practice Address - City:GIRARD
Practice Address - State:PA
Practice Address - Zip Code:16417-1241
Practice Address - Country:US
Practice Address - Phone:814-460-1464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN284401164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse