Provider Demographics
NPI:1932262557
Name:NORMAN, KELLI ANN (PA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:NORMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-371-3730
Mailing Address - Fax:814-371-9335
Practice Address - Street 1:100 MEADOW LN
Practice Address - Street 2:SUITE 4
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2460
Practice Address - Country:US
Practice Address - Phone:814-371-3730
Practice Address - Fax:814-371-9335
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052613363A00000X
PAOA002263363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA351550Q09Medicare PIN
PA111043FFUMedicare PIN