Provider Demographics
NPI:1033842588
Name:MCGOWAN, KELLY EILEEN (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:EILEEN
Last Name:MCGOWAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2171 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2937
Mailing Address - Country:US
Mailing Address - Phone:631-858-2190
Mailing Address - Fax:
Practice Address - Street 1:2171 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2937
Practice Address - Country:US
Practice Address - Phone:631-858-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF349322-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily