Healthcare Provider Details

I. General information

NPI: 1790450617
Provider Name (Legal Business Name): KELLY JANE NASIATKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2021
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

IV. Provider business mailing address

1065 SOUTHERN BLVD
BRONX NY
10459-2417
US

V. Phone/Fax

Practice location:
  • Phone: 718-589-2440
  • Fax:
Mailing address:
  • Phone: 718-589-2440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number003053
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: