Provider Demographics
NPI:1598283608
Name:KELLY, RICHARD (RN)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9115 RIDGE BLVD APT 4B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-5724
Mailing Address - Country:US
Mailing Address - Phone:917-500-1453
Mailing Address - Fax:
Practice Address - Street 1:9115 RIDGE BLVD APT 4B
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-5724
Practice Address - Country:US
Practice Address - Phone:917-500-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide