Provider Demographics
NPI:1275557852
Name:KELLY, SAMANTHA A (CRNA)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194-04 111TH ROAD
Mailing Address - Street 2:
Mailing Address - City:ST. ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-2019
Mailing Address - Country:US
Mailing Address - Phone:718-479-0245
Mailing Address - Fax:
Practice Address - Street 1:1000 N. VILLAGE AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570
Practice Address - Country:US
Practice Address - Phone:516-705-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY487061367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR0C581Medicare ID - Type Unspecified