1528492535 NPI number — KELLY M BOESCH CRNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528492535 NPI number — KELLY M BOESCH CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOESCH
Provider First Name:
KELLY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PETERSON
Provider Other First Name:
KELLY
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528492535
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 300
Provider Second Line Business Mailing Address:
4TH & WILLOW STREETS
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17042-0300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-270-7780
Provider Business Mailing Address Fax Number:
717-274-9746

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
618 CORNWALL RD
Provider Second Line Business Practice Location Address:
BUILDING 2
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17042-7089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-279-6700
Provider Business Practice Location Address Fax Number:
717-279-6759
Provider Enumeration Date:
08/27/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  SP013294 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SP013294 . This is a "LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 102888103 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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