Provider Demographics
NPI:1851086136
Name:CORONADO, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CORONADO
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 1:9123 220TH ST
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 S OYSTER BAY RD STE 102
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3500
Practice Address - Country:US
Practice Address - Phone:631-240-3579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist