Provider Demographics
NPI:1568292639
Name:ROONEY, KELLYANN (CPNP-PC)
Entity type:Individual
Prefix:
First Name:KELLYANN
Middle Name:
Last Name:ROONEY
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459-2417
Mailing Address - Country:US
Mailing Address - Phone:203-415-9386
Mailing Address - Fax:
Practice Address - Street 1:1065 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459-2417
Practice Address - Country:US
Practice Address - Phone:718-589-4755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF383735-01363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics