Provider Demographics
NPI:1609423821
Name:HERAGHTY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HERAGHTY
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 1:40 KINGFISHER RD
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-2130
Mailing Address - Country:US
Mailing Address - Phone:516-395-4465
Mailing Address - Fax:
Practice Address - Street 1:1175 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4939
Practice Address - Country:US
Practice Address - Phone:631-376-0001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344263363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily