# KAG PROFESSIONAL NURSE PRACTITIONER IN ADULT HEALTH PLLC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1295391985
- **Authorized official:** KELLY ANN GODBERSON NP (NURSE PRACTITIONER)
- **Authorized official phone:** (631) 872-2995

## Contact information

- **Practice address:** 3115 HORSEBLOCK RD, MEDFORD, NY 11763-2526
- **Practice address phone:** (631) 872-2995
- **Mailing address:** 32 MARLIN RD, CENTEREACH, NY 11720-3012
- **Mailing address phone:** (631) 872-2995

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 363LA2200X | Adult Health Nurse Practitioner | — | NULL | Yes |
| 363LA2200X | Adult Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 05/17/2019
- **Last updated:** 10/24/2022