MEDICARE: KELLY MARIE CARLIN RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	771317	NY

General Provider Information

NPI Number	:	1114573771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MARIE CARLIN RN

Provider Business Mailing Address
First Line	:	1408 SWEET HOME RD
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14228-2783
Country	:	US
Telephone Number	:	716-247-5281
Fax Number	:	716-204-0670

Provider Business Practice Location Address
First Line	:	1408 SWEET HOME RD
Second Line	:
City	:	BUFFALO
State	:	NY
Zip	:	14228-2783
Country	:	US
Telephone Number	:	716-247-5281
Fax Number	:	716-204-0670

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2019
Last Update Date	:	08/09/2019

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