Provider Demographics
NPI:1386334977
Name:KHAN, KELLIE LYNN (CRNP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:LYNN
Last Name:KHAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:CASKER AND ALLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1086 EDSON AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4445
Mailing Address - Country:US
Mailing Address - Phone:814-244-1458
Mailing Address - Fax:
Practice Address - Street 1:1086 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-4305
Practice Address - Country:US
Practice Address - Phone:814-534-1484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027508363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner