Healthcare Provider Details

I. General information

NPI: 1336838333
Provider Name (Legal Business Name): KELLY ZODL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-5144
US

IV. Provider business mailing address

601 ELMWOOD AVE
ROCHESTER NY
14642-5144
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-4501
  • Fax:
Mailing address:
  • Phone: 585-275-4501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number717528
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number404960
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: