Provider Demographics
NPI:1730475278
Name:LEVINE, KELLY ANN (PA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:LEVINE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:BURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:200 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 365
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4235
Mailing Address - Country:US
Mailing Address - Phone:516-294-5440
Mailing Address - Fax:516-294-1206
Practice Address - Street 1:200 OLD COUNTRY ROAD
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501
Practice Address - Country:US
Practice Address - Phone:516-294-5440
Practice Address - Fax:516-294-1206
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009741-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant