Provider Demographics
NPI:1487094645
Name:KELLY, GERALDINE M (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:GERALDINE
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
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Mailing Address - Street 1:11 SANDALWOOD AVE
Mailing Address - Street 2:APT. #2
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-2079
Mailing Address - Country:US
Mailing Address - Phone:917-903-6498
Mailing Address - Fax:
Practice Address - Street 1:11 SANDALWOOD AVE
Practice Address - Street 2:APT. #2
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-2079
Practice Address - Country:US
Practice Address - Phone:917-903-6498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF306515363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health