Healthcare Provider Details

I. General information

NPI: 1346657962
Provider Name (Legal Business Name): KELSEY A MIRABAL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELSEY A TALLEY

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 06/30/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 CULVER RD
ROCHESTER NY
14622-2876
US

IV. Provider business mailing address

7 SENECA ST
HORNELL NY
14843-1312
US

V. Phone/Fax

Practice location:
  • Phone: 585-266-4000
  • Fax: 585-266-4004
Mailing address:
  • Phone: 607-324-5626
  • Fax: 607-324-1374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number17693
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number017693
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: