Provider Demographics
NPI:1457627770
Name:KELLY, EVELYN PATRICIA (RN)
Entity Type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:PATRICIA
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 1:3711 21ST AVE
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1838
Mailing Address - Country:US
Mailing Address - Phone:718-545-5890
Mailing Address - Fax:
Practice Address - Street 1:3711 21ST AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11105-1838
Practice Address - Country:US
Practice Address - Phone:718-545-5890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY408025-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse