Basic Information
| Provider Information | |||||||||
| NPI: | 1639843147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCRAPE | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ERSKINE | ||||||||
| OtherFirstName: | KELLEY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 424 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORKED RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087314654 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 424 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FORKED RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087314654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099713500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2021 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 26NJ01124500 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.