Healthcare Provider Details

I. General information

NPI: 1891621421
Provider Name (Legal Business Name): MARYAM BETHANY KELLY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7785 N STATE ST
LOWVILLE NY
13367-1229
US

IV. Provider business mailing address

7195 NUMBER FOUR RD
LOWVILLE NY
13367-3237
US

V. Phone/Fax

Practice location:
  • Phone: 315-376-5200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: