Provider Demographics
NPI:1871781948
Name:DEAN, KELLY A (RN)
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:A
Last Name:DEAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-4605
Mailing Address - Country:US
Mailing Address - Phone:631-772-2259
Mailing Address - Fax:
Practice Address - Street 1:170 MADISON ST
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-4605
Practice Address - Country:US
Practice Address - Phone:631-772-2259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-13
Last Update Date:2007-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00568237163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02720574Medicaid