Provider Demographics
NPI:1346777612
Name:LABOUF, KELLY MARIE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:LABOUF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:JANACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:393 WAGNER ST LOT 81
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:NY
Mailing Address - Zip Code:13165-6709
Mailing Address - Country:US
Mailing Address - Phone:607-662-5705
Mailing Address - Fax:
Practice Address - Street 1:393 WAGNER ST LOT 81
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:NY
Practice Address - Zip Code:13165-6709
Practice Address - Country:US
Practice Address - Phone:607-662-5705
Practice Address - Fax:607-662-5705
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-17
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284963164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse