Provider Demographics
NPI:1598207631
Name:FARRELL, KELLYJEAN (RN)
Entity Type:Individual
Prefix:
First Name:KELLYJEAN
Middle Name:
Last Name:FARRELL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 LOTUS RD
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1736
Mailing Address - Country:US
Mailing Address - Phone:631-218-0604
Mailing Address - Fax:631-244-5814
Practice Address - Street 1:3 LOTUS RD
Practice Address - Street 2:
Practice Address - City:BAYPORT
Practice Address - State:NY
Practice Address - Zip Code:11705-1736
Practice Address - Country:US
Practice Address - Phone:631-218-0604
Practice Address - Fax:631-244-5814
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22527877163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool