Healthcare Provider Details

I. General information

NPI: 1669573614
Provider Name (Legal Business Name): KELLI B YOUNG MSN,CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 CIVIC CENTER BLVD
PHILADELPHIA PA
19104-4306
US

IV. Provider business mailing address

207 PELHAM RD
PHILADELPHIA PA
19119-2624
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-5657
  • Fax: 215-590-2447
Mailing address:
  • Phone: 215-842-0905
  • Fax: 215-590-2447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberVP003706O
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: