Provider Demographics
NPI:1154849792
Name:SHUSTER, KELLIE SUZANNE
Entity Type:Individual
Prefix:MS
First Name:KELLIE
Middle Name:SUZANNE
Last Name:SHUSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 TIGER LILLY DR.
Mailing Address - Street 2:
Mailing Address - City:ALIQUIPPA
Mailing Address - State:PA
Mailing Address - Zip Code:15001
Mailing Address - Country:US
Mailing Address - Phone:703-300-3930
Mailing Address - Fax:
Practice Address - Street 1:4200 5TH AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213
Practice Address - Country:US
Practice Address - Phone:412-624-4141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-04
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA$$$$$$$$$OtherNONE