Provider Demographics
NPI:1225363138
Name:KELCHNER, KIM MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:KELCHNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1207
Mailing Address - Country:US
Mailing Address - Phone:607-758-9977
Mailing Address - Fax:607-758-9907
Practice Address - Street 1:103 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1207
Practice Address - Country:US
Practice Address - Phone:607-758-9977
Practice Address - Fax:607-758-9907
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336063363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03423030Medicaid
NYJ400101732Medicare PIN