Provider Demographics
NPI:1154672731
Name:SQUIRE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SQUIRE
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 1:1024 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:NY
Mailing Address - Zip Code:14103-1030
Mailing Address - Country:US
Mailing Address - Phone:585-478-2721
Mailing Address - Fax:
Practice Address - Street 1:1024 PARK AVE
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:NY
Practice Address - Zip Code:14103-1030
Practice Address - Country:US
Practice Address - Phone:585-478-2721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist