Provider Demographics
NPI:1386714590
Name:KELLY, COLLEEN J (RNP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:RNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 E 201ST ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-1840
Mailing Address - Country:US
Mailing Address - Phone:718-696-4060
Mailing Address - Fax:718-562-4357
Practice Address - Street 1:WALTON HIGH SCHOOL
Practice Address - Street 2:2780 RESERVOIR AVENUE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468
Practice Address - Country:US
Practice Address - Phone:718-696-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF330661363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner