Provider Demographics
NPI:1255394128
Name:KELLY-TOBIN, ALICE MARY (NP)
Entity type:Individual
Prefix:
First Name:ALICE MARY
Middle Name:
Last Name:KELLY-TOBIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-2009
Mailing Address - Country:US
Mailing Address - Phone:631-737-6179
Mailing Address - Fax:
Practice Address - Street 1:41 AVENUE A
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-2009
Practice Address - Country:US
Practice Address - Phone:631-737-6179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340282-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology