Provider Demographics
NPI:1639137771
Name:HUDOCK, KELLY A (CRNP)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:A
Last Name:HUDOCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 N CEDAR CREST BLVD STE 110B
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-2351
Mailing Address - Country:US
Mailing Address - Phone:610-973-1410
Mailing Address - Fax:610-973-1442
Practice Address - Street 1:1605 N CEDAR CREST BLVD STE 110B
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-2351
Practice Address - Country:US
Practice Address - Phone:610-973-1410
Practice Address - Fax:610-973-1442
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNN095449NJ207Q00000X
PAVP006579B363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2318736OtherAETNA
NJ223733353OtherHORIZON
NJ8440506Medicaid
NJ046084Medicare ID - Type Unspecified
NJ8440506Medicaid
NJ223733353OtherHORIZON
P26362Medicare UPIN