Healthcare Provider Details

I. General information

NPI: 1336576305
Provider Name (Legal Business Name): KELLY MARIE PRALL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY MARIE PIDGEON

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

677 KIDDER STREET
WILKES-BARRE TWP. PA
18702
US

IV. Provider business mailing address

677 KIDDER STREET
WILKES-BARRE TWP. PA
18702
US

V. Phone/Fax

Practice location:
  • Phone: 570-825-2046
  • Fax:
Mailing address:
  • Phone: 570-825-2046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberOA003966
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA056199
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: