Provider Demographics
NPI:1629844766
Name:ANTONELLOS, KELLIE ANNE (APN)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANNE
Last Name:ANTONELLOS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ROBBINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08691-3162
Mailing Address - Country:US
Mailing Address - Phone:609-448-4353
Mailing Address - Fax:
Practice Address - Street 1:1 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:ROBBINSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08691-3162
Practice Address - Country:US
Practice Address - Phone:609-448-4353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14963800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner