Provider Demographics
NPI:1861453052
Name:KELLY, KIMBERLY JOYCE (AUD)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:JOYCE
Last Name:KELLY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 CAROL LYNN DR
Mailing Address - Street 2:
Mailing Address - City:WILLOW STREET
Mailing Address - State:PA
Mailing Address - Zip Code:17584-9364
Mailing Address - Country:US
Mailing Address - Phone:717-464-2144
Mailing Address - Fax:717-464-4255
Practice Address - Street 1:100 HIGHLANDS DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-7693
Practice Address - Country:US
Practice Address - Phone:717-627-4327
Practice Address - Fax:717-627-2690
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT055864174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA071669RX3Medicare ID - Type Unspecified