Provider Demographics
NPI:1255880753
Name:MALONE, KELLY (FNP-BC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MALONE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 ELM ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2941
Mailing Address - Country:US
Mailing Address - Phone:917-449-8811
Mailing Address - Fax:
Practice Address - Street 1:366 KING ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2333
Practice Address - Country:US
Practice Address - Phone:413-586-8315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-25
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22658687163WN0800X
MARN2312500163WN0800X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience