Provider Demographics
NPI:1558706416
Name:ROSARIO, KELLY ANN
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:ROSARIO
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 1:94 BROOKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-4916
Mailing Address - Country:US
Mailing Address - Phone:151-677-6094
Mailing Address - Fax:
Practice Address - Street 1:94 BROOKSIDE AVE
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-4916
Practice Address - Country:US
Practice Address - Phone:151-677-6094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136713174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist