Healthcare Provider Details

I. General information

NPI: 1083114391
Provider Name (Legal Business Name): LOUISA FUOCO KELSEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FOREST AVE
BUFFALO NY
14213-1207
US

IV. Provider business mailing address

400 FOREST AVE
BUFFALO NY
14213-1207
US

V. Phone/Fax

Practice location:
  • Phone: 716-816-2178
  • Fax: 716-816-2193
Mailing address:
  • Phone: 716-816-2178
  • Fax: 716-816-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number464649
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: