Provider Demographics
NPI:1215535042
Name:PENGITORE, KELSEY LYN (ATHLETIC TRAINER)
Entity Type:Individual
Prefix:MS
First Name:KELSEY
Middle Name:LYN
Last Name:PENGITORE
Suffix:
Gender:F
Credentials:ATHLETIC TRAINER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 HUDSON PL APT 2
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4010
Mailing Address - Country:US
Mailing Address - Phone:973-997-9158
Mailing Address - Fax:
Practice Address - Street 1:111 MADISON AVE STE 110
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6083
Practice Address - Country:US
Practice Address - Phone:862-260-7174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001888002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
25MT00188800OtherLICENSE NUMBER