Healthcare Provider Details

I. General information

NPI: 1801747522
Provider Name (Legal Business Name): KALA PEARL VANDEMARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2026
Last Update Date: 02/07/2026
Certification Date: 02/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PROSPECT ST
EAST STROUDSBURG PA
18301-2956
US

IV. Provider business mailing address

22 CANAL ST
WYALUSING PA
18853-7541
US

V. Phone/Fax

Practice location:
  • Phone: 570-422-3211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: