Provider Demographics
NPI:1013434927
Name:WALSH, KELLY ANN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WALSH
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 1:72 OLD RD
Mailing Address - Street 2:
Mailing Address - City:SEWAREN
Mailing Address - State:NJ
Mailing Address - Zip Code:07077-1242
Mailing Address - Country:US
Mailing Address - Phone:732-379-1237
Mailing Address - Fax:
Practice Address - Street 1:317 E 34TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4974
Practice Address - Country:US
Practice Address - Phone:732-379-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01327700363LA2200X
NYF308267-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF308267-1OtherLICENSE NUMBER