Provider Demographics
NPI:1124392352
Name:KELLY, SARENA (MSN, FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:SARENA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3203 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4225
Mailing Address - Country:US
Mailing Address - Phone:203-371-0009
Mailing Address - Fax:203-371-0091
Practice Address - Street 1:3203 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4225
Practice Address - Country:US
Practice Address - Phone:203-371-0009
Practice Address - Fax:203-371-0091
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004938363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTFMedicare UPIN