Healthcare Provider Details

I. General information

NPI: 1255333258
Provider Name (Legal Business Name): KELLY A BAILEY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 UPPER GLEN ST
QUEENSBURY NY
12804-2032
US

IV. Provider business mailing address

4 ATRIUM DR SUITE 100, ATTN: TAMMY M. BUTTON
ALBANY NY
12205-1441
US

V. Phone/Fax

Practice location:
  • Phone: 518-793-1083
  • Fax: 518-793-0953
Mailing address:
  • Phone: 518-435-2740
  • Fax: 518-458-2610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number332300
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: