Provider Demographics
NPI:1417693409
Name:KELLY, MARY K (LPN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HEFFERNAN
Mailing Address - Street 1:PO BOX 1696
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03244-1696
Mailing Address - Country:US
Mailing Address - Phone:160-349-3184
Mailing Address - Fax:
Practice Address - Street 1:94 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:NH
Practice Address - Zip Code:03244
Practice Address - Country:US
Practice Address - Phone:160-349-3184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-11
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH012404-22164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse