Provider Demographics
NPI:1306017066
Name:KELLY, MARTHA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:KELLY
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 1:110 REHILL AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-2598
Mailing Address - Country:US
Mailing Address - Phone:908-685-2200
Mailing Address - Fax:
Practice Address - Street 1:110 REHILL AVENUE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2598
Practice Address - Country:US
Practice Address - Phone:908-685-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN05732600363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care