Healthcare Provider Details

I. General information

NPI: 1992568356
Provider Name (Legal Business Name): KELLY MARIA DOYLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY MARIA GASNICK

II. Dates (important events)

Enumeration Date: 01/30/2024
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 RINGWOOD AVE
HASKELL NJ
07420-1408
US

IV. Provider business mailing address

33 LARCH AVE
DUMONT NJ
07628-1222
US

V. Phone/Fax

Practice location:
  • Phone: 201-350-7225
  • Fax:
Mailing address:
  • Phone: 201-674-5695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ14980400
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: