Provider Demographics
NPI:1407405046
Name:KELLEY, LINDA C.
Entity Type:Individual
Prefix:
First Name:LINDA C.
Middle Name:
Last Name:KELLEY
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 1:149 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1434
Mailing Address - Country:US
Mailing Address - Phone:585-377-2230
Mailing Address - Fax:585-377-2243
Practice Address - Street 1:28 CROSSWINDS CIR
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-9421
Practice Address - Country:US
Practice Address - Phone:585-747-5169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist