Provider Demographics
NPI:1891333258
Name:CONNELLY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8695 INTERCHANGE RD
Mailing Address - Street 2:
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-5613
Mailing Address - Country:US
Mailing Address - Phone:570-406-6294
Mailing Address - Fax:
Practice Address - Street 1:528 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:PALMERTON
Practice Address - State:PA
Practice Address - Zip Code:18071-1911
Practice Address - Country:US
Practice Address - Phone:610-900-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-17
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021237363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily