Provider Demographics
NPI:1477151280
Name:DISTELRATH, KELLY M (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:DISTELRATH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8150 PERRY HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15237-5200
Mailing Address - Country:US
Mailing Address - Phone:724-741-0044
Mailing Address - Fax:412-369-9566
Practice Address - Street 1:3601 MCKNIGHT EAST DR
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-6400
Practice Address - Country:US
Practice Address - Phone:412-369-9943
Practice Address - Fax:412-369-9447
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0027728363L00000X
PASP022823363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103876840-0001Medicaid