Provider Demographics
NPI:1215747308
Name:COPPOLA, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COPPOLA
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 1:255 CLUBHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07748-1324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:540 BORDENTOWN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08879-1546
Practice Address - Country:US
Practice Address - Phone:732-720-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR13540100163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)