Provider Demographics
NPI:1891031928
Name:SHAFER, KALLIE (CRNP)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:
Last Name:SHAFER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KALLIE
Other - Middle Name:ROSE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:1370 WASHINGTON PIKE STE 107
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15017-2889
Mailing Address - Country:US
Mailing Address - Phone:412-221-0160
Mailing Address - Fax:
Practice Address - Street 1:1370 WASHINGTON PIKE STE 107
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15017-2889
Practice Address - Country:US
Practice Address - Phone:412-221-0160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012633208000000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics