Provider Demographics
NPI:1962428904
Name:KELLY, ROBERTA MAY (FNP)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:MAY
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 DUNDERBERG RD.
Mailing Address - Street 2:
Mailing Address - City:TOMKINS COVE
Mailing Address - State:NY
Mailing Address - Zip Code:10986-1003
Mailing Address - Country:US
Mailing Address - Phone:845-270-2793
Mailing Address - Fax:
Practice Address - Street 1:1543 INWOOD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-2001
Practice Address - Country:US
Practice Address - Phone:718-681-8700
Practice Address - Fax:718-294-4765
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334983363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily