Provider Demographics
NPI:1578240164
Name:NERLICH, KELLIANNE MARIE
Entity Type:Individual
Prefix:
First Name:KELLIANNE
Middle Name:MARIE
Last Name:NERLICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12829 E CANAL DR
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT LAKE
Mailing Address - State:PA
Mailing Address - Zip Code:16316-5811
Mailing Address - Country:US
Mailing Address - Phone:814-758-1901
Mailing Address - Fax:
Practice Address - Street 1:751 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2559
Practice Address - Country:US
Practice Address - Phone:814-333-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant