Healthcare Provider Details

I. General information

NPI: 1063117125
Provider Name (Legal Business Name): KELLY ELIZABETH MAWN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 2ND STREET SUITE E509
MINEOLA NY
11501
US

IV. Provider business mailing address

649 E 14TH ST APT 5D
NEW YORK NY
10009-3112
US

V. Phone/Fax

Practice location:
  • Phone: 718-866-4569
  • Fax: 718-223-4437
Mailing address:
  • Phone: 631-901-4833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number833708-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: