=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255605135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE LYNN KELLY CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2012
-----------------------------------------------------
Last Update Date | 06/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 MANOR AVE
-----------------------------------------------------
City | LANGHORNE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-757-7667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41 UNIVERSITY DR STE 300
-----------------------------------------------------
City | NEWTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18940-1873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-710-7037
-----------------------------------------------------
Fax | 215-710-5181
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | SP011775
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------