Provider Demographics
NPI:1679032189
Name:KELLY, LAUREN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 CHASE RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19087-1228
Mailing Address - Country:US
Mailing Address - Phone:610-213-9974
Mailing Address - Fax:
Practice Address - Street 1:96 CHASE RD
Practice Address - Street 2:
Practice Address - City:CHESTERBROOK
Practice Address - State:PA
Practice Address - Zip Code:19087-1228
Practice Address - Country:US
Practice Address - Phone:610-213-9974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020054363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty