Provider Demographics
NPI:1457480501
Name:KLECKNER, KATIE ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ELIZABETH
Last Name:KLECKNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ELIZABETH
Other - Last Name:SCANLON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4755 OGLETOWN STANTON RD STE 2670
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718-2200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 2670
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-4054
Practice Address - Country:US
Practice Address - Phone:302-733-2438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA030461207XP3100X
DEC5-0000604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery