Provider Demographics
NPI:1104334655
Name:VANWYCK, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VANWYCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ROUTE 46 E STE 450
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-1583
Mailing Address - Country:US
Mailing Address - Phone:973-559-3700
Mailing Address - Fax:
Practice Address - Street 1:477 ROUTE 10 STE 205
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:NJ
Practice Address - Zip Code:07869-2144
Practice Address - Country:US
Practice Address - Phone:973-560-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00792600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily