Healthcare Provider Details

I. General information

NPI: 1134383946
Provider Name (Legal Business Name): DELOISA I KELLEY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 N MAIN ST
CANANDAIGUA NY
14424-1446
US

IV. Provider business mailing address

42 N MAIN ST
CANANDAIGUA NY
14424-1446
US

V. Phone/Fax

Practice location:
  • Phone: 585-919-0014
  • Fax:
Mailing address:
  • Phone: 585-919-0014
  • Fax: 585-919-0014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number404488
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: