Provider Demographics
NPI:1669982781
Name:REILLY, KELLY ANNE (APRN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:REILLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 NORTHWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-1658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-545-9395
Practice Address - Fax:860-545-8422
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7271363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics