Provider Demographics
NPI:1649603200
Name:KELLY, LETITIA (RN)
Entity type:Individual
Prefix:MS
First Name:LETITIA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:LETITIA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:1561 KIMBALL ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3503
Mailing Address - Country:US
Mailing Address - Phone:347-524-5253
Mailing Address - Fax:
Practice Address - Street 1:1561 KIMBALL ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-3503
Practice Address - Country:US
Practice Address - Phone:347-524-5253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-17
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY355129363LP2300X
GARN224647163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty