Healthcare Provider Details

I. General information

NPI: 1073404919
Provider Name (Legal Business Name): JENNIFER LAUREN KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 03/01/2026
Certification Date: 03/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 MAPLE AVE FL 9
WHITE PLAINS NY
10601-4706
US

IV. Provider business mailing address

122 MAPLE AVE FL 9
WHITE PLAINS NY
10601-4706
US

V. Phone/Fax

Practice location:
  • Phone: 914-948-1000
  • Fax:
Mailing address:
  • Phone: 914-948-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number312327
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: