Healthcare Provider Details

I. General information

NPI: 1972834703
Provider Name (Legal Business Name): KELLIE RENEE ATLAS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N WOOD AVE
LINDEN NJ
07036-4147
US

IV. Provider business mailing address

520 N WOOD AVE
LINDEN NJ
07036-4147
US

V. Phone/Fax

Practice location:
  • Phone: 908-587-9300
  • Fax: 908-587-1901
Mailing address:
  • Phone: 908-587-9300
  • Fax: 908-587-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN312613
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00338600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: