Healthcare Provider Details

I. General information

NPI: 1245537265
Provider Name (Legal Business Name): KELLY FIELD BONNEVILLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY NICOLE FIELD PA-C

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 04/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N DUKE ST
LANCASTER PA
17602-2250
US

IV. Provider business mailing address

555 N DUKE ST FL 3
LANCASTER PA
17602-2250
US

V. Phone/Fax

Practice location:
  • Phone: 717-544-5945
  • Fax: 717-544-5944
Mailing address:
  • Phone: 717-544-5945
  • Fax: 717-544-5944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA054788
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: