Provider Demographics
NPI:1598198525
Name:DOUGLASS, KELLY (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:JAMISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1201 GRAMPIAN BLVD
Mailing Address - Street 2:SUITE 1K
Mailing Address - City:WILLIAMSPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17701-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 WARREN AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17701-2665
Practice Address - Country:US
Practice Address - Phone:570-326-8500
Practice Address - Fax:570-326-8049
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013049363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner