Provider Demographics
NPI:1699052415
Name:KELLY, SANDRA (PA)
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:11010-1332
Mailing Address - Country:US
Mailing Address - Phone:516-328-6252
Mailing Address - Fax:516-900-3452
Practice Address - Street 1:320 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN SQUARE
Practice Address - State:NY
Practice Address - Zip Code:11010
Practice Address - Country:US
Practice Address - Phone:516-328-6252
Practice Address - Fax:516-900-3452
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007187-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant