MEDICARE: MARY F KELLEY CRNP

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	363LG0600X	Gerontology Nurse Practitioner	VP002188H	PA

General Provider Information

NPI Number	:	1477876928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY F KELLEY CRNP

Provider Business Mailing Address
First Line	:	330 S 9TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-6103
Country	:	US
Telephone Number	:	215-829-3053
Fax Number	:

Provider Business Practice Location Address
First Line	:	330 S 9TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-6103
Country	:	US
Telephone Number	:	215-829-3053
Fax Number	:

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

Provider Enumeration Date	:	03/11/2010
Last Update Date	:	04/04/2014

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