Healthcare Provider Details

I. General information

NPI: 1841854023
Provider Name (Legal Business Name): KELLY VANESSA MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 PINEBROOK AVE
WEST HEMPSTEAD NY
11552-4310
US

IV. Provider business mailing address

581 PINEBROOK AVE
WEST HEMPSTEAD NY
11552-4310
US

V. Phone/Fax

Practice location:
  • Phone: 516-324-9188
  • Fax:
Mailing address:
  • Phone: 516-324-9188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number761201
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: