Provider Demographics
NPI:1528457124
Name:SHIPLE, KELLY (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SHIPLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 W SPROUL RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-1254
Mailing Address - Country:US
Mailing Address - Phone:484-472-8812
Mailing Address - Fax:
Practice Address - Street 1:905 W SPROUL RD
Practice Address - Street 2:SUITE 106
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-1254
Practice Address - Country:US
Practice Address - Phone:484-472-8812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant