Provider Demographics
NPI:1710157318
Name:WONG, KELLY (MSN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WONG
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 HENRY AVE
Mailing Address - Street 2:PHILADELPHIA UNIVERSITY, STUDENT HEALTH CENTER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-5409
Mailing Address - Country:US
Mailing Address - Phone:215-951-2986
Mailing Address - Fax:215-951-6867
Practice Address - Street 1:4201 HENRY AVE
Practice Address - Street 2:PHILADELPHIA UNIVERSITY, STUDENT HEALTH CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-5409
Practice Address - Country:US
Practice Address - Phone:215-951-2986
Practice Address - Fax:215-951-6867
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009541363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily