Provider Demographics
NPI:1629521877
Name:KELTY, ERICA ELIZABETH (RN)
Entity Type:Individual
Prefix:MISS
First Name:ERICA
Middle Name:ELIZABETH
Last Name:KELTY
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 1:156 ELIN ST
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-3603
Mailing Address - Country:US
Mailing Address - Phone:631-513-7187
Mailing Address - Fax:
Practice Address - Street 1:110 LAKE AVE S
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-1088
Practice Address - Country:US
Practice Address - Phone:631-265-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-24
Last Update Date:2016-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY718673163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY718673OtherREGISTERED PRACTICING NURSE