Provider Demographics
NPI:1871268011
Name:RIVELL, KELLY ANNE (APN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:RIVELL
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SAINT REGIS DR
Mailing Address - Street 2:
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-3928
Mailing Address - Country:US
Mailing Address - Phone:609-410-7557
Mailing Address - Fax:
Practice Address - Street 1:PBF ENERGY
Practice Address - Street 2:800 BILLINGSPORT ROAD
Practice Address - City:PAULSBOR
Practice Address - State:NJ
Practice Address - Zip Code:08066
Practice Address - Country:US
Practice Address - Phone:856-224-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01156100363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NJ01156100OtherOCCUPATIONAL HEALTH APN