Provider Demographics
NPI:1235275959
Name:KELLY, MAUREEN JEANETTE (PA)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:JEANETTE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4624
Mailing Address - Country:US
Mailing Address - Phone:631-366-0679
Mailing Address - Fax:
Practice Address - Street 1:68 HAUPPAUGE RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4403
Practice Address - Country:US
Practice Address - Phone:631-715-2503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003748-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYZ87691Medicare ID - Type Unspecified
NYS51701Medicare UPIN