Provider Demographics
NPI:1902077514
Name:RUPERT, KELLY L (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:RUPERT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1204 QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:POTTSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19464-5832
Mailing Address - Country:US
Mailing Address - Phone:610-858-2753
Mailing Address - Fax:
Practice Address - Street 1:1204 QUEEN ST
Practice Address - Street 2:
Practice Address - City:POTTSTOWN
Practice Address - State:PA
Practice Address - Zip Code:19464-5832
Practice Address - Country:US
Practice Address - Phone:610-858-2753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-22
Last Update Date:2008-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN273623164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse