Provider Demographics
NPI:1659368595
Name:KELLY, SUSAN R (APRN)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:R
Last Name:KELLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:R
Other - Last Name:CARNEGIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03064-2716
Mailing Address - Country:US
Mailing Address - Phone:603-883-0005
Mailing Address - Fax:603-883-0007
Practice Address - Street 1:1 MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03064
Practice Address - Country:US
Practice Address - Phone:603-883-0005
Practice Address - Fax:603-883-0007
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHRN048-042-21363LP0808X
NH048042-23364SP0809X
NHAPRN048042-23363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH40V001351NH01OtherANTHEM
NHRE6599Medicare ID - Type Unspecified
NH40V001351NH01OtherANTHEM
P52466Medicare UPIN