Provider Demographics
NPI:1598057424
Name:DESANCTIS, KELLI K (DO)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:K
Last Name:DESANCTIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:K
Other - Last Name:WIENECKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:2501 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4527
Mailing Address - Country:US
Mailing Address - Phone:814-461-6626
Mailing Address - Fax:814-871-6351
Practice Address - Street 1:2501 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4527
Practice Address - Country:US
Practice Address - Phone:814-461-6626
Practice Address - Fax:814-871-6351
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS016944207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine