Healthcare Provider Details

I. General information

NPI: 1760541619
Provider Name (Legal Business Name): MRS. KELLY L ELDREDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5151 W LAKE RD
CANANDAIGUA NY
14424-8953
US

IV. Provider business mailing address

6368 MURPHY DR
VICTOR NY
14564-9204
US

V. Phone/Fax

Practice location:
  • Phone: 585-396-1602
  • Fax:
Mailing address:
  • Phone: 585-924-8137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number210532-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: