Provider Demographics
NPI:1467254425
Name:WISNIEWSKI, KELLY JEAN (AGNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:WISNIEWSKI
Suffix:
Gender:
Credentials:AGNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 FRANKEL RD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-7260
Mailing Address - Country:US
Mailing Address - Phone:516-780-2096
Mailing Address - Fax:
Practice Address - Street 1:100 PORT WASHINTON BLVD
Practice Address - Street 2:
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576
Practice Address - Country:US
Practice Address - Phone:516-390-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312048363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health