Provider Demographics
NPI:1366465593
Name:PATENAUDE, KELLI LEIGH (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:LEIGH
Last Name:PATENAUDE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 427
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:NY
Mailing Address - Zip Code:12170-0427
Mailing Address - Country:US
Mailing Address - Phone:518-664-4525
Mailing Address - Fax:518-664-1256
Practice Address - Street 1:172 HUDSON AVE.
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:NY
Practice Address - Zip Code:12170-0427
Practice Address - Country:US
Practice Address - Phone:518-664-4525
Practice Address - Fax:518-664-1256
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011154111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10110754OtherCDPHP
NY1065576OtherASHN
NYX08P31OtherBLUE CROSS / BLUE SHIELD
NY20406141101OtherPRISM HEALTH NETWORK
NYNY11154OtherMVP HEALTH PLAN
NYC11154-4WOtherWORKERS' COMPENSATION
NY204061411OtherLANDMARK
NY204061411OtherLANDMARK
V08680Medicare UPIN