Basic Information
| Provider Information | |||||||||
| NPI: | 1700937877 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PICERNO | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 206 E BROWN ST | ||||||||
| Address2: | POCONO HEALTHCARE MGMT - PROFESSIONAL BLDG | ||||||||
| City: | E STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183013006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704204969 | ||||||||
| FaxNumber: | 5704763754 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 VETERANS PL | ||||||||
| Address2: | PMC LEARNING INSTITUTE | ||||||||
| City: | STROUDSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 183602494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704261688 | ||||||||
| FaxNumber: | 5704261832 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 07/29/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0102X | RN349793L | PA | Y | Nursing Service Providers | Registered Nurse | Maternal Newborn |
ID Information
| ID | Type | State | Issuer | Description | 1016058300001 | 05 | PA | MEDICAID |