1417351958 NPI number — KELLY LEESE MISERENDINO PAC

Table of content: KELLY LEESE MISERENDINO PAC (NPI 1417351958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417351958 NPI number — KELLY LEESE MISERENDINO PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISERENDINO
Provider First Name:
KELLY
Provider Middle Name:
LEESE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEESE
Provider Other First Name:
KELLY
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417351958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3421 CONCORD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YORK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17402-9001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-812-5400
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
228 SAINT CHARLES WAY STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17402-4661
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-812-5400
Provider Business Practice Location Address Fax Number:
717-741-3598
Provider Enumeration Date:
10/13/2014

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: 2084P0800X , with the licence number:  0110006374 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: MA057146 , 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)