Provider Demographics
NPI:1023848132
Name:KELLY, SOPHIA
Entity type:Individual
Prefix:
First Name:SOPHIA
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 1:587 CENTRAL AVE # 304
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-1019
Mailing Address - Country:US
Mailing Address - Phone:862-367-2461
Mailing Address - Fax:
Practice Address - Street 1:587 CENTRAL AVE # 304
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1019
Practice Address - Country:US
Practice Address - Phone:862-367-2461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No372600000XNursing Service Related ProvidersAdult Companion
No385H00000XRespite Care FacilityRespite Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child