Provider Demographics
NPI:1215229596
Name:NUSSBAUM, KELLY (APRN)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:NUSSBAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:9 RICKER RD
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405
Mailing Address - Country:US
Mailing Address - Phone:973-838-8869
Mailing Address - Fax:
Practice Address - Street 1:163 ENGLE ST STE 4A
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2530
Practice Address - Country:US
Practice Address - Phone:201-408-4487
Practice Address - Fax:800-352-3015
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NC07471600364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult