Healthcare Provider Details

I. General information

NPI: 1043883572
Provider Name (Legal Business Name): KELLY HILAIRE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11358 212TH ST
QUEENS VILLAGE NY
11429-2312
US

IV. Provider business mailing address

11944 218TH ST
CAMBRIA HEIGHTS NY
11411-1911
US

V. Phone/Fax

Practice location:
  • Phone: 718-954-3553
  • Fax: 877-762-6647
Mailing address:
  • Phone: 718-954-3553
  • Fax: 877-762-6647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number347853
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: