Provider Demographics
NPI:1467573329
Name:KELLY, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 ROLLER RD
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-3428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:572 COOKMAN AVE
Practice Address - Street 2:
Practice Address - City:ASBURY PARK
Practice Address - State:NJ
Practice Address - Zip Code:07712-7102
Practice Address - Country:US
Practice Address - Phone:732-774-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NC08508900207R00000X, 364SP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJS38280Medicare UPIN