Provider Demographics
NPI:1205293131
Name:PESZKO, KELLY A
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:PESZKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:DIPAOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 BALA PLZ
Mailing Address - Street 2:SUITE IL-27
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 BALA PLZ
Practice Address - Street 2:SUITE IL-27
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1501
Practice Address - Country:US
Practice Address - Phone:610-668-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-22
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015608363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health