Provider Demographics
NPI:1639868458
Name:BOOTH, KELLIE H (CRNP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:H
Last Name:BOOTH
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 1:400 W LANCASTER AVE
Mailing Address - Street 2:
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333-1531
Mailing Address - Country:US
Mailing Address - Phone:610-851-4800
Mailing Address - Fax:
Practice Address - Street 1:400 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-1531
Practice Address - Country:US
Practice Address - Phone:610-851-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027493363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health