Provider Demographics
NPI:1205646015
Name:PENDER, KELLY ANNE (LMT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:PENDER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-1514
Mailing Address - Country:US
Mailing Address - Phone:551-689-0059
Mailing Address - Fax:
Practice Address - Street 1:30 PROVOST ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-5866
Practice Address - Country:US
Practice Address - Phone:551-689-0763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT01012100225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist