Provider Demographics
NPI:1417351958
Name:MISERENDINO, KELLY LEESE (PAC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEESE
Last Name:MISERENDINO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:LEESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:3421 CONCORD RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-9001
Mailing Address - Country:US
Mailing Address - Phone:717-812-5400
Mailing Address - Fax:
Practice Address - Street 1:228 SAINT CHARLES WAY STE 300
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-4661
Practice Address - Country:US
Practice Address - Phone:717-812-5400
Practice Address - Fax:717-741-3598
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01100063742084P0800X
PAMA057146363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP01478274Medicare PIN