Provider Demographics
NPI:1639263411
Name:LANDRY, KEALA
Entity Type:Individual
Prefix:
First Name:KEALA
Middle Name:
Last Name:LANDRY
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 1:201 E 12TH ST
Mailing Address - Street 2:APT. PH7
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-9128
Mailing Address - Country:US
Mailing Address - Phone:917-533-9537
Mailing Address - Fax:
Practice Address - Street 1:355 GRAND ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4321
Practice Address - Country:US
Practice Address - Phone:201-915-2218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07788400207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00204475OtherRAILROAD
P00204475OtherRAILROAD
089869Medicare PIN