Provider Demographics
NPI:1447517776
Name:KELLENBERGER, TRACY ANN (PA-C)
Entity type:Individual
Prefix:MS
First Name:TRACY
Middle Name:ANN
Last Name:KELLENBERGER
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 1:90 WOODS AVE
Mailing Address - Street 2:
Mailing Address - City:CONESTOGA
Mailing Address - State:PA
Mailing Address - Zip Code:17516-9586
Mailing Address - Country:US
Mailing Address - Phone:717-872-5646
Mailing Address - Fax:
Practice Address - Street 1:306 N 7TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:PA
Practice Address - Zip Code:17512-2137
Practice Address - Country:US
Practice Address - Phone:717-684-9106
Practice Address - Fax:717-684-1666
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055406363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant