Healthcare Provider Details

I. General information

NPI: 1922317783
Provider Name (Legal Business Name): SEAN KELLEY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 09/28/2010
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: 716-816-2991
  • Fax:
Mailing address:
  • Phone: 716-816-2991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number562476
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: