Provider Demographics
NPI:1407206428
Name:BECK, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3842 MYSTIC MEADOWS LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:NY
Mailing Address - Zip Code:14589-9549
Mailing Address - Country:US
Mailing Address - Phone:585-409-8027
Mailing Address - Fax:
Practice Address - Street 1:3842 MYSTIC MEADOWS LN
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:NY
Practice Address - Zip Code:14589-9549
Practice Address - Country:US
Practice Address - Phone:585-409-8027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320512-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY30Medicaid