Provider Demographics
NPI:1134517204
Name:WESCOTT, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WESCOTT
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 1:3132 6TH AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-1201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3132 6TH AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-1201
Practice Address - Country:US
Practice Address - Phone:518-892-4162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-24
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273968-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse