Healthcare Provider Details

I. General information

NPI: 1063804920
Provider Name (Legal Business Name): KELLY MCLEAN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 NIAGARA ST
BUFFALO NY
14201
US

IV. Provider business mailing address

564 NIAGARA ST
BUFFALO NY
14201-1108
US

V. Phone/Fax

Practice location:
  • Phone: 716-882-0366
  • Fax:
Mailing address:
  • Phone: 716-882-0366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number633253
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number344322
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: