Provider Demographics
NPI:1730597360
Name:WHEELER, KELLY (CRNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WHEELER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 OAK PL
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07704-3510
Mailing Address - Country:US
Mailing Address - Phone:732-768-7857
Mailing Address - Fax:
Practice Address - Street 1:201 LYONS AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112-2027
Practice Address - Country:US
Practice Address - Phone:973-926-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2025-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY382415363LP0200X
NJ26NJ0048730363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics