Provider Demographics
NPI:1932241981
Name:KELLEY, T. NICOLE (RN, MS, CRNP)
Entity Type:Individual
Prefix:MRS
First Name:T. NICOLE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN, MS, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 S FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:RED LION
Mailing Address - State:PA
Mailing Address - Zip Code:17356-9189
Mailing Address - Country:US
Mailing Address - Phone:717-880-9788
Mailing Address - Fax:410-328-8862
Practice Address - Street 1:22 S GREENE ST RM T6R44
Practice Address - Street 2:UNIVERSTIY OF MD, MEDICAL SYSTEM, SHOCK TRAUMA CENTER
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-3058
Practice Address - Fax:410-328-8862
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR100906363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR100906OtherRN & CRNP LICENSE NUMBERS