Provider Demographics
NPI:1790119501
Name:REGIS, KETTY (FNP)
Entity Type:Individual
Prefix:MS
First Name:KETTY
Middle Name:
Last Name:REGIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3264 CAMBRIDGE AVE
Mailing Address - Street 2:2ND FL
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-3619
Mailing Address - Country:US
Mailing Address - Phone:305-332-6566
Mailing Address - Fax:
Practice Address - Street 1:3264 CAMBRIDGE AVE
Practice Address - Street 2:2ND FL
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-3619
Practice Address - Country:US
Practice Address - Phone:305-332-6566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF337571-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily