Healthcare Provider Details

I. General information

NPI: 1114392735
Provider Name (Legal Business Name): KELLY SULLIVAN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2015
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 W CRESCENT PARK
WARREN PA
16365-2111
US

IV. Provider business mailing address

2 W CRESCENT PARK
WARREN PA
16365-2111
US

V. Phone/Fax

Practice location:
  • Phone: 814-723-3300
  • Fax: 814-726-9412
Mailing address:
  • Phone: 814-723-3300
  • Fax: 814-726-9412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP015625
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License NumberSP015625
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: