Provider Demographics
NPI:1871883959
Name:WENKO, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WENKO
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 1:765 LIBERTY ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MEADVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16335-2566
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:765 LIBERTY ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2566
Practice Address - Country:US
Practice Address - Phone:814-333-5888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011351363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP011351OtherPENNSYLVANIA DEPARTMENT OF STATE