Provider Demographics
NPI:1962804054
Name:KELLY, CHRISTAL
Entity type:Individual
Prefix:
First Name:CHRISTAL
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BAY ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2511
Mailing Address - Country:US
Mailing Address - Phone:718-447-7740
Mailing Address - Fax:718-313-1657
Practice Address - Street 1:50 BAY ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2511
Practice Address - Country:US
Practice Address - Phone:718-447-7740
Practice Address - Fax:718-313-1657
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309109164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse