Provider Demographics
NPI:1669266219
Name:SHANNON, KELLEY KOMETA (RN)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:KOMETA
Last Name:SHANNON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD FL 4
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:1259 S CEDAR CREST BLVD STE 230
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6376
Practice Address - Country:US
Practice Address - Phone:610-402-5900
Practice Address - Fax:610-402-4650
Is Sole Proprietor?:No
Enumeration Date:2025-04-08
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PARN663117163W00000X
PASP032895363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse