Basic Information
| Provider Information | |||||||||
| NPI: | 1528492535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOESCH | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PETERSON | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CRNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 300 | ||||||||
| Address2: | 4TH & WILLOW STREETS | ||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170420300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172707780 | ||||||||
| FaxNumber: | 7172749746 | ||||||||
| Practice Location | |||||||||
| Address1: | 618 CORNWALL RD | ||||||||
| Address2: | BUILDING 2 | ||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170427089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172796700 | ||||||||
| FaxNumber: | 7172796759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2013 | ||||||||
| LastUpdateDate: | 11/06/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | SP013294 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | SP013294 | 01 | PA | LICENSE | OTHER | 102888103 0001 | 05 | PA | MEDICAID |