Provider Demographics
NPI:1326621491
Name:RICKARD, KELLI JO (LPN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JO
Last Name:RICKARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 170
Mailing Address - Street 2:
Mailing Address - City:IRVONA
Mailing Address - State:PA
Mailing Address - Zip Code:16656-0170
Mailing Address - Country:US
Mailing Address - Phone:814-932-8305
Mailing Address - Fax:814-240-5812
Practice Address - Street 1:3438 ROUTE 764
Practice Address - Street 2:
Practice Address - City:DUNCANSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16635-7803
Practice Address - Country:US
Practice Address - Phone:814-944-7000
Practice Address - Fax:814-240-5812
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN289554164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse