Basic Information
| Provider Information | |||||||||
| NPI: | 1639137771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUDOCK | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1605 N CEDAR CREST BLVD STE 110B | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181042351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109731410 | ||||||||
| FaxNumber: | 6109731442 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 N CEDAR CREST BLVD STE 110B | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181042351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109731410 | ||||||||
| FaxNumber: | 6109731442 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 12/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | NN095449NJ | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 363LF0000X | VP006579B | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | VP006579B | PA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2318736 | 01 | NJ | AETNA | OTHER | 223733353 | 01 | NJ | HORIZON | OTHER | 8440506 | 05 | NJ | MEDICAID |