Provider Demographics
NPI:1689954570
Name:O'LEARY, KELLY ANN (RN)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:ANN
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 393
Mailing Address - Street 2:
Mailing Address - City:SHENOROCK
Mailing Address - State:NY
Mailing Address - Zip Code:10587-0393
Mailing Address - Country:US
Mailing Address - Phone:914-844-7454
Mailing Address - Fax:
Practice Address - Street 1:4377 BRONX BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-1397
Practice Address - Country:US
Practice Address - Phone:914-844-7454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY647303-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse