Provider Demographics
NPI:1548801020
Name:AMAYA, KELLY VANESSA
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:VANESSA
Last Name:AMAYA
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 1:815 COMMACK RD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-7409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3001 EXPRESSWAY DR N
Practice Address - Street 2:
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-5301
Practice Address - Country:US
Practice Address - Phone:631-292-6747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344697363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily