Provider Demographics
NPI:1811718901
Name:BERTOLAZZI, KELLYN O (MSN, RN)
Entity type:Individual
Prefix:
First Name:KELLYN
Middle Name:O
Last Name:BERTOLAZZI
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-1310
Mailing Address - Country:US
Mailing Address - Phone:484-566-5464
Mailing Address - Fax:
Practice Address - Street 1:2246 BUSTARD RD
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446-5717
Practice Address - Country:US
Practice Address - Phone:610-308-1349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN283246L163WA2000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator