Provider Demographics
NPI:1306058714
Name:KELLY, MARY CATHERINE (PNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:KELLY
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 1:275 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CT
Mailing Address - Zip Code:06878-2313
Mailing Address - Country:US
Mailing Address - Phone:203-698-7403
Mailing Address - Fax:
Practice Address - Street 1:275 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CT
Practice Address - Zip Code:06878-2313
Practice Address - Country:US
Practice Address - Phone:203-698-7403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381068-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics