Provider Demographics
NPI:1891232500
Name:EARL, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EARL
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:PO BOX 22581
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-2581
Mailing Address - Country:US
Mailing Address - Phone:610-482-4795
Mailing Address - Fax:856-528-3117
Practice Address - Street 1:499 BECKETT RD STE 202
Practice Address - Street 2:
Practice Address - City:SWEDESBORO
Practice Address - State:NJ
Practice Address - Zip Code:08085-1771
Practice Address - Country:US
Practice Address - Phone:856-325-3760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00574000363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner