Provider Demographics
NPI:1215378740
Name:KELLY, SEAN MICHAEL (GNP-BC)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:GNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W 106TH ST OFC
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3923
Mailing Address - Country:US
Mailing Address - Phone:347-501-2299
Mailing Address - Fax:
Practice Address - Street 1:1 PENN PLZ FL 8
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10119-0899
Practice Address - Country:US
Practice Address - Phone:347-213-8011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340958363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology