Healthcare Provider Details

I. General information

NPI: 1205234903
Provider Name (Legal Business Name): KELLY ELAINE CROWLEY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY ELAINE WIGHT APN

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

30 PROSPECT AVE # TCI
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 201-487-8987
  • Fax:
Mailing address:
  • Phone: 201-487-8987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00540800
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1205234903
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: