Provider Demographics
NPI:1831802875
Name:MAR, KELCEY
Entity type:Individual
Prefix:
First Name:KELCEY
Middle Name:
Last Name:MAR
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 1:44 STATE RT 23 STE 6
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07457-1603
Mailing Address - Country:US
Mailing Address - Phone:973-248-9199
Mailing Address - Fax:
Practice Address - Street 1:44 STATE RT 23 STE 6
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:NJ
Practice Address - Zip Code:07457-1603
Practice Address - Country:US
Practice Address - Phone:973-248-9199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-04
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY350533363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily