MEDICARE: MS. KELLY ELIZABETH MOHEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1770821308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY ELIZABETH MOHEN

Provider Business Mailing Address
First Line	:	112 4TH ST
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-5934
Country	:	US
Telephone Number	:	516-581-8204
Fax Number	:

Provider Business Practice Location Address
First Line	:	112 4TH ST
Second Line	:
City	:	GARDEN CITY
State	:	NY
Zip	:	11530-5934
Country	:	US
Telephone Number	:	516-581-8204
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2013
Last Update Date	:	01/16/2013

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