Healthcare Provider Details

I. General information

NPI: 1508346347
Provider Name (Legal Business Name): KELLY MARIE MERRILL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY MARIE MERRILL

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SMITH ROAD
RIDGE NY
11961
US

IV. Provider business mailing address

75 SMITH RD
RIDGE NY
11961-2542
US

V. Phone/Fax

Practice location:
  • Phone: 914-384-1065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number756382
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: