Healthcare Provider Details

I. General information

NPI: 1023131554
Provider Name (Legal Business Name): CYNTHIA JEAN KELLEY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 HOLLY LN
PILESGROVE NJ
08098-2414
US

IV. Provider business mailing address

44 HOLLY LN
PILESGROVE NJ
08098-2414
US

V. Phone/Fax

Practice location:
  • Phone: 856-769-1591
  • Fax:
Mailing address:
  • Phone: 856-769-1591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberLM-0000101
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number26NN07510600
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberR133433
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: