Healthcare Provider Details

I. General information

NPI: 1619503588
Provider Name (Legal Business Name): KELLY O'BOYLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SAINT ANDREWS LN
GLEN COVE NY
11542-2254
US

IV. Provider business mailing address

101 SAINT ANDREWS LN
GLEN COVE NY
11542-2254
US

V. Phone/Fax

Practice location:
  • Phone: 516-674-7300
  • Fax:
Mailing address:
  • Phone: 516-674-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number345900
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number345900
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: