Healthcare Provider Details

I. General information

NPI: 1720994205
Provider Name (Legal Business Name): KAITLIN KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 GRANT ST APT 3F
MONTCLAIR NJ
07042-4874
US

IV. Provider business mailing address

5 GRANT ST APT 3F
MONTCLAIR NJ
07042-4874
US

V. Phone/Fax

Practice location:
  • Phone: 609-442-4097
  • Fax:
Mailing address:
  • Phone: 609-442-5097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: