Basic Information
| Provider Information | |||||||||
| NPI: | 1235799628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 W. BEECH ST | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115613211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164317600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 AMSTERDAM AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100251716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125234000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2019 | ||||||||
| LastUpdateDate: | 07/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F344063-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.