Provider Demographics
NPI:1114249604
Name:MUSCO, KELLYANN MARIE (RN)
Entity Type:Individual
Prefix:MS
First Name:KELLYANN
Middle Name:MARIE
Last Name:MUSCO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:KELLYANN
Other - Middle Name:MARIE
Other - Last Name:DEDES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30 GALLEY HILL RD
Mailing Address - Street 2:
Mailing Address - City:CUDDEBACKVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12729-5204
Mailing Address - Country:US
Mailing Address - Phone:845-754-8756
Mailing Address - Fax:845-754-7141
Practice Address - Street 1:30 GALLEY HILL RD
Practice Address - Street 2:
Practice Address - City:CUDDEBACKVILLE
Practice Address - State:NY
Practice Address - Zip Code:12729-5204
Practice Address - Country:US
Practice Address - Phone:845-754-8756
Practice Address - Fax:845-754-7141
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY646048163W00000X
NY270219164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse