Provider Demographics
NPI:1235644030
Name:KELLY, REBECCA ANN
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ANN
Other - Last Name:KNOWLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4852 ROUTE 81
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12083
Mailing Address - Country:US
Mailing Address - Phone:518-966-4800
Mailing Address - Fax:518-966-4950
Practice Address - Street 1:4852 ROUTE 81
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12083
Practice Address - Country:US
Practice Address - Phone:518-966-4800
Practice Address - Fax:518-966-4950
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062946183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist