Healthcare Provider Details

I. General information

NPI: 1508354788
Provider Name (Legal Business Name): KELSEY HEFFERNAN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 COOPER PLZ
CAMDEN NJ
08103
US

IV. Provider business mailing address

1 FEDERAL ST STE SW200
CAMDEN NJ
08103-1155
US

V. Phone/Fax

Practice location:
  • Phone: 800-826-6737
  • Fax:
Mailing address:
  • Phone: 856-356-4924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP018313
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00793700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: