Provider Demographics
NPI:1063117125
Name:MAWN, KELLY ELIZABETH (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:MAWN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:649 E 14TH ST APT 5D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-3112
Mailing Address - Country:US
Mailing Address - Phone:631-901-4833
Mailing Address - Fax:
Practice Address - Street 1:199 2ND STREET
Practice Address - Street 2:SUITE E509
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501
Practice Address - Country:US
Practice Address - Phone:718-866-4569
Practice Address - Fax:718-223-4437
Is Sole Proprietor?:No
Enumeration Date:2023-03-30
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY833708-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse