Provider Demographics
NPI:1508503632
Name:KELLY, TARA MARIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4704
Mailing Address - Country:US
Mailing Address - Phone:516-377-2820
Mailing Address - Fax:
Practice Address - Street 1:2119 MERRICK RD
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-4704
Practice Address - Country:US
Practice Address - Phone:516-377-2820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-19
Last Update Date:2022-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY347883363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily