Provider Demographics
NPI:1477028199
Name:SHAPIRO, KELLIE (CRNP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:SHAPIRO
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 1:50 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LEMOYNE
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1440
Mailing Address - Country:US
Mailing Address - Phone:717-234-2561
Mailing Address - Fax:717-236-1121
Practice Address - Street 1:50 N 12TH ST
Practice Address - Street 2:
Practice Address - City:LEMOYNE
Practice Address - State:PA
Practice Address - Zip Code:17043-1440
Practice Address - Country:US
Practice Address - Phone:717-234-2561
Practice Address - Fax:717-236-1121
Is Sole Proprietor?:No
Enumeration Date:2018-10-09
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP019387363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007770587-0009Medicaid