Provider Demographics
NPI:1417184268
Name:MIKOLOSKO, KELLI MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:MIKOLOSKO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 S CEDAR CREST BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6258
Mailing Address - Country:US
Mailing Address - Phone:610-402-9099
Mailing Address - Fax:610-402-9029
Practice Address - Street 1:1200 S CEDAR CREST BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6202
Practice Address - Country:US
Practice Address - Phone:610-402-9099
Practice Address - Fax:610-402-9029
Is Sole Proprietor?:No
Enumeration Date:2009-06-19
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN-564095163W00000X
PA082609367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027800840001Medicaid
PA2112787OtherHIGHMARK
PA1585159OtherGATEWAY
PA3723133000OtherIBC
PA50086413OtherCAPITAL ADVANTAGE
PA11976788OtherCAQH
PA127848OtherGEISINGER
PA2112787OtherFIRST PRIORITY
PA9769481OtherAETNA
PA2112787OtherHIGHMARK
PA2112787OtherFIRST PRIORITY