MEDICARE: KELLY LEESE MISERENDINO PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	MA057146	PA
2	2084P0800X	Psychiatry Physician	0110006374	VA

General Provider Information

NPI Number	:	1417351958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LEESE MISERENDINO PAC

Provider Business Mailing Address
First Line	:	601 MEMORY LN
Second Line	:
City	:	YORK
State	:	PA
Zip	:	17402-2231
Country	:	US
Telephone Number	:	717-851-1405
Fax Number	:	717-851-6969

Provider Business Practice Location Address
First Line	:	228 SAINT CHARLES WAY STE 300
Second Line	:
City	:	YORK
State	:	PA
Zip	:	17402-4661
Country	:	US
Telephone Number	:	717-812-5400
Fax Number	:	717-741-3598

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2014
Last Update Date	:	04/10/2026

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Directions to “ KELLY LEESE MISERENDINO PAC” Practice Location

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