Healthcare Provider Details

I. General information

NPI: 1184930836
Provider Name (Legal Business Name): KELY CRISTINA JERONIMO P.A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 SUMMIT AVE DEPT OF SURGERY
PROVIDENCE RI
02906-3418
US

IV. Provider business mailing address

125 METRO CENTER BLVD STE 2000
WARWICK RI
02886-1785
US

V. Phone/Fax

Practice location:
  • Phone: 774-287-4181
  • Fax:
Mailing address:
  • Phone: 401-432-2520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA7655
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA549
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: