Healthcare Provider Details

I. General information

NPI: 1023217098
Provider Name (Legal Business Name): PATRICIA MARIE KELLY MSED
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 OAK DR
CALVERTON NY
11933-1100
US

IV. Provider business mailing address

66 OAK DR
CALVERTON NY
11933-1100
US

V. Phone/Fax

Practice location:
  • Phone: 631-727-1705
  • Fax:
Mailing address:
  • Phone: 631-727-1705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: