Provider Demographics
NPI:1417522715
Name:KELLY, MARY (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WEST ST APT 2918
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-1033
Mailing Address - Country:US
Mailing Address - Phone:914-439-4627
Mailing Address - Fax:
Practice Address - Street 1:1 WEST ST APT 2918
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004-1033
Practice Address - Country:US
Practice Address - Phone:914-439-4627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY581847163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management