Healthcare Provider Details

I. General information

NPI: 1679840722
Provider Name (Legal Business Name): KELLY ANN BEATON RILEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2011
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HO PLZ
ITHACA NY
14853-3102
US

IV. Provider business mailing address

PO BOX 98
TRUMANSBURG NY
14886-0098
US

V. Phone/Fax

Practice location:
  • Phone: 607-255-5155
  • Fax:
Mailing address:
  • Phone: 607-351-2787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number406510-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF344651-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: