Healthcare Provider Details

I. General information

NPI: 1427786920
Provider Name (Legal Business Name): KELLIE GROMACKI CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2022
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PEACH ST STE 200
ERIE PA
16507-1423
US

IV. Provider business mailing address

100 PEACH ST STE 200
ERIE PA
16507-1423
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-7733
  • Fax:
Mailing address:
  • Phone: 814-877-7733
  • Fax: 814-456-7213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP026089
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: