Provider Demographics
NPI:1093136467
Name:MCMAHON, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 840
Mailing Address - Street 2:
Mailing Address - City:HARRIS
Mailing Address - State:NY
Mailing Address - Zip Code:12742-0840
Mailing Address - Country:US
Mailing Address - Phone:845-707-8495
Mailing Address - Fax:845-707-8499
Practice Address - Street 1:641 OLD ROUTE 17
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-7014
Practice Address - Country:US
Practice Address - Phone:845-707-8495
Practice Address - Fax:845-707-8499
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10263696164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse