Provider Demographics
NPI:1326412503
Name:KELLY, KATHERINE LOUISA (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:LOUISA
Last Name:KELLY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:LOUISA
Other - Last Name:GOEPEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071-1518
Mailing Address - Country:US
Mailing Address - Phone:856-364-0051
Mailing Address - Fax:
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-3481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-25
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015643363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care