Healthcare Provider Details

I. General information

NPI: 1093857005
Provider Name (Legal Business Name): KRISTEN KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 CO RT 64
MEXICO NY
13114
US

IV. Provider business mailing address

216 CO RT 64
MEXICO NY
13114
US

V. Phone/Fax

Practice location:
  • Phone: 315-963-5421
  • Fax:
Mailing address:
  • Phone: 315-963-5421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0263941
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: