Provider Demographics
NPI:1558803809
Name:KELLY, MARY JO ANNE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY JO
Middle Name:ANNE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 WHITEHEAD ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-2406
Mailing Address - Country:US
Mailing Address - Phone:609-771-3777
Mailing Address - Fax:609-771-8041
Practice Address - Street 1:1014 WHITEHEAD ROAD EXT
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08638-2406
Practice Address - Country:US
Practice Address - Phone:609-771-3777
Practice Address - Fax:609-771-8041
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00669700363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health