Provider Demographics
NPI:1407197072
Name:KELLY, CAROLYN ANN (FNP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:WATERBURY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:111 OSBORNE ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-6000
Mailing Address - Country:US
Mailing Address - Phone:917-968-6543
Mailing Address - Fax:
Practice Address - Street 1:11 OSBORNE ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5918
Practice Address - Country:US
Practice Address - Phone:203-739-7131
Practice Address - Fax:203-739-1554
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005298363LF0000X
NYF337508-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily