Provider Demographics
NPI:1972691079
Name:KELLY, MARY MARGARET (APN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:MARGARET
Last Name:KELLY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 TERRACE AVE
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-2905
Mailing Address - Country:US
Mailing Address - Phone:973-473-3896
Mailing Address - Fax:
Practice Address - Street 1:116 TERRACE AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-2905
Practice Address - Country:US
Practice Address - Phone:973-473-3896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNN42981163W00000X
NJ26NN04298100363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ003589Medicare ID - Type UnspecifiedMEDICARE