Provider Demographics
NPI:1578857892
Name:MATTHEWS, KELLY A (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:MATTHEWS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:A
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 STERLING ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2530
Mailing Address - Country:US
Mailing Address - Phone:631-946-3167
Mailing Address - Fax:
Practice Address - Street 1:200 STERLING ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2530
Practice Address - Country:US
Practice Address - Phone:631-946-3167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-03
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3056061164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse