Provider Demographics
NPI:1528573490
Name:SHANK, KELLY RENEE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENEE
Last Name:SHANK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:RENEE
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:128 VALLEYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:PA
Mailing Address - Zip Code:16059-1430
Mailing Address - Country:US
Mailing Address - Phone:724-263-6598
Mailing Address - Fax:
Practice Address - Street 1:102 TECHNOLOGY DR STE 210E
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001-1784
Practice Address - Country:US
Practice Address - Phone:724-284-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN547582163W00000X
PASP018303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse