Provider Demographics
NPI:1639681414
Name:HUDGINS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HUDGINS
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 1:180 6TH AVE RM 138
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3507
Mailing Address - Country:US
Mailing Address - Phone:718-230-5707
Mailing Address - Fax:
Practice Address - Street 1:180 6TH AVE RM 138
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-3507
Practice Address - Country:US
Practice Address - Phone:718-230-5707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-01
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2311946163W00000X, 363LP0200X
NY383313363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse