Provider Demographics
NPI:1104712843
Name:COLE, KELLY ANN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:COLE
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 1:3619 COUNTY ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:12865-4703
Mailing Address - Country:US
Mailing Address - Phone:518-448-3340
Mailing Address - Fax:
Practice Address - Street 1:120 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-5002
Practice Address - Country:US
Practice Address - Phone:802-440-4077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF356998-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily