Provider Demographics
NPI:1750056495
Name:SWABY, KEMPOLLY DATISHA
Entity Type:Individual
Prefix:MS
First Name:KEMPOLLY
Middle Name:DATISHA
Last Name:SWABY
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 1:531 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-2122
Mailing Address - Country:US
Mailing Address - Phone:973-941-6617
Mailing Address - Fax:
Practice Address - Street 1:531 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-2122
Practice Address - Country:US
Practice Address - Phone:973-941-6617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-13
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01183500363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology