Healthcare Provider Details

I. General information

NPI: 1962428904
Provider Name (Legal Business Name): ROBERTA MAY KELLY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1543 INWOOD AVE
BRONX NY
10452-2001
US

IV. Provider business mailing address

3 DUNDERBERG RD.
TOMKINS COVE NY
10986-1003
US

V. Phone/Fax

Practice location:
  • Phone: 718-681-8700
  • Fax: 718-294-4765
Mailing address:
  • Phone: 845-270-2793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number334983
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: