Healthcare Provider Details

I. General information

NPI: 1265501951
Provider Name (Legal Business Name): IRENE A KELLY APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 RIVERVIEW PLZ
RED BANK NJ
07701-1864
US

IV. Provider business mailing address

26 GULL RD
MIDDLETOWN NJ
07748-3244
US

V. Phone/Fax

Practice location:
  • Phone: 732-450-2876
  • Fax: 732-530-2506
Mailing address:
  • Phone: 732-671-0541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number26NJ00032900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: