Provider Demographics
NPI:1477749828
Name:LATTANZI, KELLY DARRAGH (CRNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DARRAGH
Last Name:LATTANZI
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 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-707-1800
Mailing Address - Fax:215-707-3644
Practice Address - Street 1:3322 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5185
Practice Address - Country:US
Practice Address - Phone:215-707-1800
Practice Address - Fax:215-707-3644
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN527774L163W00000X
PASP009526363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022508560001Medicaid