MEDICARE: KELLY LIDDELL MSN, RN, SANE-P

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN672978	PA

General Provider Information

NPI Number	:	1285568493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY LIDDELL MSN, RN, SANE-P

Provider Business Mailing Address
First Line	:	126 SPRING ST
Second Line	:
City	:	MEDIA
State	:	PA
Zip	:	19063-4944
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	126 SPRING ST
Second Line	:
City	:	MEDIA
State	:	PA
Zip	:	19063-4944
Country	:	US
Telephone Number	:	814-863-7374
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2026
Last Update Date	:	06/11/2026

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