Provider Demographics
NPI:1275158115
Name:KOONTZ, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:KOONTZ
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 1:121 TOWNE SQUARE DR STE 301
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-9440
Mailing Address - Country:US
Mailing Address - Phone:717-988-8320
Mailing Address - Fax:717-221-5397
Practice Address - Street 1:121 TOWNE SQUARE DR STE 301
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-9440
Practice Address - Country:US
Practice Address - Phone:717-988-8320
Practice Address - Fax:717-221-5397
Is Sole Proprietor?:No
Enumeration Date:2020-06-16
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061679363A00000X
PAOA005245363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant