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General NPI Number Information
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NPI Number | 1740302421
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Entity Type | Individual
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Provider Name | KELLY ANN GROOM M.S. PA-C
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Gender | Female
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1803 MAHAN AVE
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City | BRONX
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State | NY
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Zip | 10461-4621
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Country | US
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Telephone | 718-409-2762
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Fax | 718-863-4432
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Provider Business Mailing Address
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Address Line | 222 E 34TH ST APARTMENT #1203
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City | NEW YORK
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State | NY
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Zip | 10016-4842
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 009403
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License Number State | NY
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