Provider Demographics
NPI:1275878225
Name:HIMES, KELLI LYN (LPN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:LYN
Last Name:HIMES
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 BARNSTEAD DR APT 5
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-1086
Mailing Address - Country:US
Mailing Address - Phone:716-572-9752
Mailing Address - Fax:
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1129
Practice Address - Country:US
Practice Address - Phone:716-834-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311088164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse