Provider Demographics
NPI:1467066506
Name:SHERIDAN, KELLY ANNE (RN)
Entity Type:Individual
Prefix:
First Name:KELLY ANNE
Middle Name:
Last Name:SHERIDAN
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 1:347 SHARON AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3418
Mailing Address - Country:US
Mailing Address - Phone:646-331-4486
Mailing Address - Fax:
Practice Address - Street 1:1535 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-1520
Practice Address - Country:US
Practice Address - Phone:929-482-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-05
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY788521-01163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool