Provider Demographics
NPI:1376705921
Name:KELLY, KARLENE (NURSE)
Entity Type:Individual
Prefix:
First Name:KARLENE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3007 ELY AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3259
Mailing Address - Country:US
Mailing Address - Phone:718-379-3250
Mailing Address - Fax:
Practice Address - Street 1:27 WINTHROP DRIVE
Practice Address - Street 2:PRIVATE HOUSE
Practice Address - City:PEEKILL
Practice Address - State:NY
Practice Address - Zip Code:10566
Practice Address - Country:US
Practice Address - Phone:914-528-3748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205303-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02528274Medicaid