Provider Demographics
NPI:1265408587
Name:TORTORELLA, KELLY (RPA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TORTORELLA
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 NORTHERN BLVD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5302
Mailing Address - Country:US
Mailing Address - Phone:516-482-1100
Mailing Address - Fax:
Practice Address - Street 1:900 NORTHERN BLVD
Practice Address - Street 2:SUITE 130
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5302
Practice Address - Country:US
Practice Address - Phone:516-482-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004765363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF69320Medicare ID - Type Unspecified