Provider Demographics
NPI:1477944635
Name:SOARES, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:SOARES
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 1:615 HOPE RD 5A
Mailing Address - Street 2:VISITING PHYSICAN SERVICES
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724
Mailing Address - Country:US
Mailing Address - Phone:732-571-1000
Mailing Address - Fax:
Practice Address - Street 1:615 HOPE RD
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1277
Practice Address - Country:US
Practice Address - Phone:732-571-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00548600363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ468114YYNZMedicare Oscar/Certification