Provider Demographics
NPI:1790924181
Name:KELLY, REGINA MARIE (RN)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:MARIE
Last Name:KELLY
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 1:1217 E MAIN ST APT 2C
Mailing Address - Street 2:
Mailing Address - City:SHRUB OAK
Mailing Address - State:NY
Mailing Address - Zip Code:10588-1442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 VERONICA CT
Practice Address - Street 2:
Practice Address - City:CORTLANDT MANOR
Practice Address - State:NY
Practice Address - Zip Code:10567-6400
Practice Address - Country:US
Practice Address - Phone:914-293-7844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22443194163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health