Provider Demographics
NPI:1033546700
Name:KELLY, HAIDANG TRUONG (NP)
Entity Type:Individual
Prefix:
First Name:HAIDANG
Middle Name:TRUONG
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HAIDANG
Other - Middle Name:THI
Other - Last Name:TRUONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:147 MILK ST FL 9
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:147 MILK ST FL 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109
Practice Address - Country:US
Practice Address - Phone:617-654-7280
Practice Address - Fax:617-654-7363
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2263216363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110022129Medicaid