Provider Demographics
NPI:1790173862
Name:WELLER, KELLY (CRNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WELLER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:500 UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2360
Mailing Address - Country:US
Mailing Address - Phone:717-531-8413
Mailing Address - Fax:717-531-1533
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:717-531-8413
Practice Address - Fax:717-531-1533
Is Sole Proprietor?:No
Enumeration Date:2014-12-24
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014561363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal