Provider Demographics
NPI:1700257565
Name:KRATZER, SHELLIE R (CRNP)
Entity type:Individual
Prefix:
First Name:SHELLIE
Middle Name:R
Last Name:KRATZER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:SHELLIE
Other - Middle Name:R
Other - Last Name:DIMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:2813 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:MIFFLINTOWN
Practice Address - State:PA
Practice Address - Zip Code:17059-9078
Practice Address - Country:US
Practice Address - Phone:717-436-8283
Practice Address - Fax:717-436-8351
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-19
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN627395163W00000X
PA024625363L00000X
PASP015565363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031720750001Medicaid
PA462444F6KOtherMEDICARE