Provider Demographics
NPI:1770964249
Name:TONGO-KELLY, MAGDALENE
Entity type:Individual
Prefix:
First Name:MAGDALENE
Middle Name:
Last Name:TONGO-KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MAGDALENE TONGO-KELLY 1698 PARK PLACE APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NEW YORK
Mailing Address - Zip Code:11233
Mailing Address - Country:UM
Mailing Address - Phone:718-773-5089
Mailing Address - Fax:
Practice Address - Street 1:1698 PARK PL APT 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11233-4508
Practice Address - Country:US
Practice Address - Phone:718-773-5089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306431363LA2200X
NY306431363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health