Provider Demographics
NPI:1912445479
Name:KELLY, JENNIE L (NP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIE
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34B BRAMAN ST
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-1942
Mailing Address - Country:US
Mailing Address - Phone:978-509-1749
Mailing Address - Fax:
Practice Address - Street 1:7 HANCOCK CIR
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-7146
Practice Address - Country:US
Practice Address - Phone:978-509-1749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2277698363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2277698OtherRN