Provider Demographics
NPI:1528492535
Name:BOESCH, KELLY M (CRNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:BOESCH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:4TH & WILLOW STREETS
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-0300
Mailing Address - Country:US
Mailing Address - Phone:717-270-7780
Mailing Address - Fax:717-274-9746
Practice Address - Street 1:618 CORNWALL RD
Practice Address - Street 2:BUILDING 2
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7089
Practice Address - Country:US
Practice Address - Phone:717-279-6700
Practice Address - Fax:717-279-6759
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013294363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP013294OtherLICENSE
PA102888103 0001Medicaid
PA102888103 0001Medicaid