Healthcare Provider Details

I. General information

NPI: 1770034373
Provider Name (Legal Business Name): KELLYANN PATRICIA CIVILETTI AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 E 34TH ST FL 3
NEW YORK NY
10016-4972
US

IV. Provider business mailing address

403 E 34TH ST FL 3
NEW YORK NY
10016-4972
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-8134
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number646983
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number308012
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: