Provider Demographics
NPI:1144791401
Name:COHEN, KELLY ANN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:COHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BANK AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2703
Mailing Address - Country:US
Mailing Address - Phone:631-265-5300
Mailing Address - Fax:
Practice Address - Street 1:17 BANK AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2703
Practice Address - Country:US
Practice Address - Phone:631-265-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333482164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse