Provider Demographics
NPI:1760658207
Name:KELLY, MARY ANN (APRN)
Entity Type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:MIDDLESEX HOSPITAL 7TH FL
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-6760
Mailing Address - Fax:860-358-4829
Practice Address - Street 1:28 CRESCENT ST
Practice Address - Street 2:MIDDLESEX HOSPITAL 7TH FL
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3654
Practice Address - Country:US
Practice Address - Phone:860-358-6760
Practice Address - Fax:860-358-4829
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003508363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003508OtherCT APRN LICENSE