Provider Demographics
NPI:1316556566
Name:FETTERHOFF, KELLY ANNA (CRNP)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:ANNA
Last Name:FETTERHOFF
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1699 POTTSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:LYKENS
Mailing Address - State:PA
Mailing Address - Zip Code:17048-9633
Mailing Address - Country:US
Mailing Address - Phone:717-395-4929
Mailing Address - Fax:
Practice Address - Street 1:205 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1619
Practice Address - Country:US
Practice Address - Phone:717-231-8360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022261363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health