Healthcare Provider Details

I. General information

NPI: 1700120540
Provider Name (Legal Business Name): MARY CAROLINE KELLEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1097 PROSPECT PL APT 1B
BROOKLYN NY
11213-2141
US

IV. Provider business mailing address

2061 KING COLLEGE RD
BRISTOL TN
37620-2919
US

V. Phone/Fax

Practice location:
  • Phone: 628-800-4217
  • Fax:
Mailing address:
  • Phone: 628-800-4217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number406358
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: