Provider Demographics
NPI:1205234903
Name:CROWLEY, KELLY ELAINE (APN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELAINE
Last Name:CROWLEY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELAINE
Other - Last Name:WIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APN
Mailing Address - Street 1:30 PROSPECT AVE # TCI
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1915
Mailing Address - Country:US
Mailing Address - Phone:201-487-8987
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1915
Practice Address - Country:US
Practice Address - Phone:201-487-8987
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-11
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00540800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1205234903Medicaid