Basic Information
| Provider Information | |||||||||
| NPI: | 1851319347 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | HIGGINS | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1235 OLD YORK RD | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | ABINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155171200 | ||||||||
| FaxNumber: | 2155171219 | ||||||||
| Practice Location | |||||||||
| Address1: | 1235 OLD YORK RD | ||||||||
| Address2: | SUITE 121 | ||||||||
| City: | ABINGTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190013800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155171200 | ||||||||
| FaxNumber: | 2155171219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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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 | 363LG0600X | TP004416C | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | TP004416C | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1224376 | 05 | PA | MEDICAID |