Provider Demographics
NPI:1336576305
Name:PRALL, KELLY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:PRALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:PIDGEON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:677 KIDDER STREET
Mailing Address - Street 2:
Mailing Address - City:WILKES-BARRE TWP.
Mailing Address - State:PA
Mailing Address - Zip Code:18702
Mailing Address - Country:US
Mailing Address - Phone:570-825-2046
Mailing Address - Fax:
Practice Address - Street 1:677 KIDDER STREET
Practice Address - Street 2:
Practice Address - City:WILKES-BARRE TWP.
Practice Address - State:PA
Practice Address - Zip Code:18702
Practice Address - Country:US
Practice Address - Phone:570-825-2046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-04
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003966363AM0700X
PAMA056199363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical