Healthcare Provider Details

I. General information

NPI: 1881978260
Provider Name (Legal Business Name): KERRYANN MELISSA PENNY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2011
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16318 JAMAICA AVE
JAMAICA NY
11432-4912
US

IV. Provider business mailing address

16318 JAMAICA AVE
JAMAICA NY
11432-4912
US

V. Phone/Fax

Practice location:
  • Phone: 347-307-5857
  • Fax: 718-275-6062
Mailing address:
  • Phone: 347-307-5857
  • Fax: 718-275-6062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number404360
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number646650
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: