Provider Demographics
NPI:1942351242
Name:KELLY, SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:MC MURRAY
Mailing Address - State:PA
Mailing Address - Zip Code:15317-3063
Mailing Address - Country:US
Mailing Address - Phone:724-969-4321
Mailing Address - Fax:724-941-6948
Practice Address - Street 1:3515 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MC MURRAY
Practice Address - State:PA
Practice Address - Zip Code:15317-3063
Practice Address - Country:US
Practice Address - Phone:724-969-4321
Practice Address - Fax:724-941-6948
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA005848363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner