Provider Demographics
NPI:1114181443
Name:KELLY, HORTENSIA (DO)
Entity Type:Individual
Prefix:DR
First Name:HORTENSIA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:851 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-3228
Mailing Address - Country:US
Mailing Address - Phone:973-481-0501
Mailing Address - Fax:973-481-0503
Practice Address - Street 1:851 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-3228
Practice Address - Country:US
Practice Address - Phone:973-481-0501
Practice Address - Fax:973-481-0503
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB08441500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine