Healthcare Provider Details

I. General information

NPI: 1124632401
Provider Name (Legal Business Name): SHANNON NOEL KELLETT LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2020
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 S SYCAMORE ST
NEWTOWN PA
18940-1533
US

IV. Provider business mailing address

6 S SYCAMORE ST
NEWTOWN PA
18940-1533
US

V. Phone/Fax

Practice location:
  • Phone: 267-968-1479
  • Fax:
Mailing address:
  • Phone: 267-968-1479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAK001334
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: