Provider Demographics
NPI:1578233102
Name:KULICK, SHANNA (CRNP)
Entity Type:Individual
Prefix:
First Name:SHANNA
Middle Name:
Last Name:KULICK
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 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:570-501-6368
Mailing Address - Fax:570-501-4754
Practice Address - Street 1:1000 ALLIANCE DR
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-3234
Practice Address - Country:US
Practice Address - Phone:570-459-2226
Practice Address - Fax:570-459-2511
Is Sole Proprietor?:No
Enumeration Date:2021-09-15
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP024627363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner