Provider Demographics
NPI:1114445277
Name:KELLEY, BETHANY CRYSTAL (PA)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:CRYSTAL
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:968 SCOTTDALE DAWSON RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:PA
Mailing Address - Zip Code:15683-2500
Mailing Address - Country:US
Mailing Address - Phone:412-302-8628
Mailing Address - Fax:
Practice Address - Street 1:110 N 13TH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:PA
Practice Address - Zip Code:16323-2312
Practice Address - Country:US
Practice Address - Phone:814-437-1541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA059249363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant