Basic Information
| Provider Information | |||||||||
| NPI: | 1316556566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FETTERHOFF | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANNA | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1699 POTTSVILLE ST | ||||||||
| Address2: | |||||||||
| City: | LYKENS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170489633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7173954929 | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 S FRONT ST | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318360 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2020 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | SP022261 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.