Provider Demographics
NPI:1275532947
Name:GOLDENBERG, KELLY ANN (CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:GOLDENBERG
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 MYRTLE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-1044
Mailing Address - Country:US
Mailing Address - Phone:518-587-2400
Mailing Address - Fax:518-581-0141
Practice Address - Street 1:59 MYRTLE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1044
Practice Address - Country:US
Practice Address - Phone:518-587-2400
Practice Address - Fax:518-581-0141
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF000738-1367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01831323Medicaid