Healthcare Provider Details

I. General information

NPI: 1508503012
Provider Name (Legal Business Name): KAITLIN KELLEY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N MAIN ST
PROVIDENCE RI
02904-5700
US

IV. Provider business mailing address

105 WASHINGTON ST APT 403
BRIGHTON MA
02135-4377
US

V. Phone/Fax

Practice location:
  • Phone: 401-648-7172
  • Fax:
Mailing address:
  • Phone: 401-855-5923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN03091
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: