Provider Demographics
NPI:1083783278
Name:KELLY, DIANE M (NP)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:8 DENISON PKWY E
Practice Address - Street 2:SUITE 201
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2638
Practice Address - Country:US
Practice Address - Phone:607-936-4143
Practice Address - Fax:607-936-6836
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF335005363LF0000X
NY335005363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02843209Medicaid
NY02843209Medicaid