Provider Demographics
NPI:1881357903
Name:MYERS, KELLY LEE (FNP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:MYERS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:EMPORIUM
Mailing Address - State:PA
Mailing Address - Zip Code:15834-0270
Mailing Address - Country:US
Mailing Address - Phone:814-486-1115
Mailing Address - Fax:
Practice Address - Street 1:49 RIDGMONT DR STE 1
Practice Address - Street 2:
Practice Address - City:RIDGWAY
Practice Address - State:PA
Practice Address - Zip Code:15853-9700
Practice Address - Country:US
Practice Address - Phone:814-245-2119
Practice Address - Fax:814-245-2122
Is Sole Proprietor?:No
Enumeration Date:2021-10-15
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP025081363LF0000X
PARN617747163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse