Healthcare Provider Details

I. General information

NPI: 1396429171
Provider Name (Legal Business Name): KELLY WHATLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2023
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 W SPROUL RD STE 200
SPRINGFIELD PA
19064-4005
US

IV. Provider business mailing address

760 W SPROUL RD STE 200
SPRINGFIELD PA
19064-4005
US

V. Phone/Fax

Practice location:
  • Phone: 215-462-7100
  • Fax:
Mailing address:
  • Phone: 484-386-6300
  • Fax: 484-380-3178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA064757
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: