Provider Demographics
NPI:1922761741
Name:GOODMAN-O'LEARY, KELLY L (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:GOODMAN-O'LEARY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:GOODMAN-O'LEARY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNP
Mailing Address - Street 1:3300 HENRY AVE STE 401
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1162
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3300 HENRY AVE STE 401
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1162
Practice Address - Country:US
Practice Address - Phone:267-571-1359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN721550163W00000X
PASP024574363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASP024574OtherCRNP LICENSE NUMBER
PARN721550OtherRN LICENSE NUMBER
MO6879689OtherDEA LICENSE