Healthcare Provider Details

I. General information

NPI: 1164652467
Provider Name (Legal Business Name): LAURA ANN KELLY RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 LIMESTONE DR
WILLIAMSVILLE NY
14221-7051
US

IV. Provider business mailing address

6255 SHERIDAN DR SUITE 304
WILLIAMSVILLE NY
14221-4836
US

V. Phone/Fax

Practice location:
  • Phone: 716-630-2517
  • Fax: 716-634-5650
Mailing address:
  • Phone: 716-857-8666
  • Fax: 716-630-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number013309-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number013309-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: