Provider Demographics
NPI:1467410340
Name:SHULTZ, KELLY S (CRNP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:S
Last Name:SHULTZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:MUNCY
Mailing Address - State:PA
Mailing Address - Zip Code:17756-8828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 E WATER ST
Practice Address - Street 2:SUSQUEHANNA HEALTH SKILLED NURSING & REHAB CENTER
Practice Address - City:MUNCY
Practice Address - State:PA
Practice Address - Zip Code:17756-8828
Practice Address - Country:US
Practice Address - Phone:570-546-4040
Practice Address - Fax:570-546-4095
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP004718B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0073317020002Medicaid
PA0073317020002Medicaid
PAP00715728Medicare PIN
PA001630Medicare PIN