Provider Demographics
NPI:1104538354
Name:MARRA, KELLY (PNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MARRA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S 1ST ST APT 3A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-4366
Mailing Address - Country:US
Mailing Address - Phone:314-378-0274
Mailing Address - Fax:
Practice Address - Street 1:207 S 1ST ST APT 3A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-4366
Practice Address - Country:US
Practice Address - Phone:314-378-0274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF383505-01363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics