Provider Demographics
NPI:1144598343
Name:KELLY, JENNIFER ELAINE (RPA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELAINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24 EAST 97TH STREET
Mailing Address - Street 2:APT #5
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029
Mailing Address - Country:US
Mailing Address - Phone:810-348-6516
Mailing Address - Fax:
Practice Address - Street 1:381 PARK AVENUE SOUTH
Practice Address - Street 2:SUITE 1020
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-260-6078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015233363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant