Provider Demographics
NPI:1700937877
Name:KELLY, KATHLEEN E (RN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:E
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:PICERNO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:206 E BROWN ST
Mailing Address - Street 2:POCONO HEALTHCARE MGMT - PROFESSIONAL BLDG
Mailing Address - City:E STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-3006
Mailing Address - Country:US
Mailing Address - Phone:570-420-4969
Mailing Address - Fax:570-476-3754
Practice Address - Street 1:2 VETERANS PL
Practice Address - Street 2:PMC LEARNING INSTITUTE
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-2494
Practice Address - Country:US
Practice Address - Phone:570-426-1688
Practice Address - Fax:570-426-1832
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN349793L163WM0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016058300001Medicaid