Provider Demographics
NPI:1861938698
Name:LIFAVI, KELLY ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:LIFAVI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:BOCCHINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1345 AVENUE OF THE AMERICAS FL 8
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10105-0018
Mailing Address - Country:US
Mailing Address - Phone:212-913-0828
Mailing Address - Fax:
Practice Address - Street 1:461 FULTON ST FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5207
Practice Address - Country:US
Practice Address - Phone:718-571-9418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-18
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant