Healthcare Provider Details

I. General information

NPI: 1316946494
Provider Name (Legal Business Name): JUDY KELLY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ST. MARY'S HOSP. FAM. HLTH. CTR. AT JOHNSVILLE 7 TIMMERMAN AVENUE
ST. JOHNSVILLE NY
13452
US

IV. Provider business mailing address

427 GUY PARK AVE - PRIMARY & SPECIALTY CARE DEPT. ST. MARY'S HOSPITAL @ AMSTERDAM
AMSTERDAM NY
12010
US

V. Phone/Fax

Practice location:
  • Phone: 518-568-7145
  • Fax: 518-568-7147
Mailing address:
  • Phone: 518-841-7430
  • Fax: 518-841-7121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number330791-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: