MEDICARE: MS. MARY KATHLEEN KELLY CRNP

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	363LP0200X	Pediatric Nurse Practitioner	UP002304D	PA

General Provider Information

NPI Number	:	1902920549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY KATHLEEN KELLY CRNP

Provider Business Mailing Address
First Line	:	336 BYRON CIR
Second Line	:
City	:	CRANBERRY TWP
State	:	PA
Zip	:	16066-4308
Country	:	US
Telephone Number	:	724-776-1758
Fax Number	:

Provider Business Practice Location Address
First Line	:	4221 PENN AVE
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15224-1307
Country	:	US
Telephone Number	:	412-681-1050
Fax Number	:	412-681-1040

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	07/08/2007

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