Provider Demographics
NPI:1679758130
Name:KELLY, KATHLEEN MARY (NP-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 MAIN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9231
Mailing Address - Country:US
Mailing Address - Phone:973-402-0025
Mailing Address - Fax:973-402-0508
Practice Address - Street 1:137 MAIN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9231
Practice Address - Country:US
Practice Address - Phone:973-402-0025
Practice Address - Fax:973-402-0508
Is Sole Proprietor?:No
Enumeration Date:2008-01-03
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPENDING363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ154825N0QMedicare PIN