Provider Demographics
NPI:1306686035
Name:HENZLER, KELLY LEE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:HENZLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 S BRYN MAWR AVE
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3201
Mailing Address - Country:US
Mailing Address - Phone:610-527-3110
Mailing Address - Fax:
Practice Address - Street 1:26 S BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3201
Practice Address - Country:US
Practice Address - Phone:610-527-3110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP022868363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology