Provider Demographics
NPI:1700335916
Name:BLYDENBURGH, KELLY A (RN)
Entity Type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:A
Last Name:BLYDENBURGH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-0069
Mailing Address - Country:US
Mailing Address - Phone:631-525-6197
Mailing Address - Fax:
Practice Address - Street 1:238 ROCKAWAY ST
Practice Address - Street 2:
Practice Address - City:ISLIP TERRACE
Practice Address - State:NY
Practice Address - Zip Code:11752-1105
Practice Address - Country:US
Practice Address - Phone:631-525-6197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY669132-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse