Provider Demographics
NPI:1659717122
Name:MATTHEW, KELSY YVONNE
Entity Type:Individual
Prefix:
First Name:KELSY
Middle Name:YVONNE
Last Name:MATTHEW
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 1:100 WESTERVELT AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-1496
Mailing Address - Country:US
Mailing Address - Phone:347-640-9144
Mailing Address - Fax:
Practice Address - Street 1:100 WESTERVELT AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-1496
Practice Address - Country:US
Practice Address - Phone:347-640-9144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287779164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse