Provider Demographics
NPI:1669818100
Name:CASANOVA, KELLY LYNN (LPN)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNN
Last Name:CASANOVA
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:WEBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:3 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-4303
Mailing Address - Country:US
Mailing Address - Phone:631-399-0322
Mailing Address - Fax:
Practice Address - Street 1:3 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-4303
Practice Address - Country:US
Practice Address - Phone:631-399-0322
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
NY245173-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility