Provider Demographics
NPI:1710984448
Name:PUPO, KELLI (CRNA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:PUPO
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 BERRY LN
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-1160
Mailing Address - Country:US
Mailing Address - Phone:610-566-5284
Mailing Address - Fax:
Practice Address - Street 1:130 SOUTH BRYN MAWR AVENUE
Practice Address - Street 2:FLOOR THREE
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010
Practice Address - Country:US
Practice Address - Phone:484-337-3000
Practice Address - Fax:610-527-5102
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN317545L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA053718Medicare ID - Type Unspecified