Provider Demographics
NPI:1922292820
Name:KELLY, MARY (APN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KELLY
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 1:1 DIAMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2104
Mailing Address - Country:US
Mailing Address - Phone:908-273-4300
Mailing Address - Fax:
Practice Address - Street 1:1 DIAMOND HILL RD
Practice Address - Street 2:
Practice Address - City:BERKELEY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07922-2104
Practice Address - Country:US
Practice Address - Phone:908-277-8890
Practice Address - Fax:908-673-7390
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00135500363L00000X
NJ26NO10993300364SX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner