Provider Demographics
NPI:1124178371
Name:CONTI, KELLY RAE
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RAE
Last Name:CONTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:SHORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:67 OHAYO MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498-1441
Mailing Address - Country:US
Mailing Address - Phone:845-679-4630
Mailing Address - Fax:
Practice Address - Street 1:67 OHAYO MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498-1441
Practice Address - Country:US
Practice Address - Phone:845-679-4630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263602-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02670184Medicaid