Basic Information
| Provider Information | |||||||||
| NPI: | 1417184268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIKOLOSKO | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1245 S CEDAR CREST BLVD STE 301 | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104029099 | ||||||||
| FaxNumber: | 6104029029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 S CEDAR CREST BLVD | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181036202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6104029099 | ||||||||
| FaxNumber: | 6104029029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2009 | ||||||||
| LastUpdateDate: | 03/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN-564095 | PA | N | Nursing Service Providers | Registered Nurse | 367500000X | 082609 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 1027800840001 | 05 | PA | MEDICAID | 2112787 | 01 | PA | HIGHMARK | OTHER | 1585159 | 01 | PA | GATEWAY | OTHER | 3723133000 | 01 | PA | IBC | OTHER | 50086413 | 01 | PA | CAPITAL ADVANTAGE | OTHER | 11976788 | 01 | PA | CAQH | OTHER | 127848 | 01 | PA | GEISINGER | OTHER | 2112787 | 01 | PA | FIRST PRIORITY | OTHER | 9769481 | 01 | PA | AETNA | OTHER |