Provider Demographics
NPI:1033803184
Name:DRAKE, KELLY LEE (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LEE
Last Name:DRAKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5467 UPPER MOUNTAIN RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-1894
Mailing Address - Country:US
Mailing Address - Phone:716-804-3613
Mailing Address - Fax:
Practice Address - Street 1:5467 UPPER MOUNTAIN RD STE 100
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-1894
Practice Address - Country:US
Practice Address - Phone:716-804-3613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY473716-01163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)