Basic Information
| Provider Information | |||||||||
| NPI: | 1326362047 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMMARBERG | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
| FaxNumber: | 7177096529 | ||||||||
| Practice Location | |||||||||
| Address1: | 283 S BUTLER RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170428939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172738871 | ||||||||
| FaxNumber: | 7172702452 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2010 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | RN525635L | PA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | SP013010 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 12637985 | 01 | CAQH ID | OTHER | SP013010 | 01 | PA | STATE LICENSE - CRNP | OTHER | SW123688 | 01 | PA | STATE LICENSE - SOCIAL WORKER | OTHER | MH2988698 | 01 | PA | FEDERAL DEA LICENSE | OTHER | 102885219 | 05 | PA | MEDICAID | RN525635L | 01 | PA | STATE LICENSE - RN | OTHER |