Provider Demographics
NPI:1780241596
Name:HALE, KELLIE ANN (NP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ANN
Last Name:HALE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:ANN
Other - Last Name:BURNS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3053 12TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-4006
Mailing Address - Country:US
Mailing Address - Phone:619-203-4084
Mailing Address - Fax:
Practice Address - Street 1:356 W 18TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4401
Practice Address - Country:US
Practice Address - Phone:212-271-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309101363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care