Provider Demographics
NPI:1407480551
Name:CUMMINGS, KELLIE (PA)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:CUMMINGS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 36363
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07188-6306
Mailing Address - Country:US
Mailing Address - Phone:845-651-1400
Mailing Address - Fax:
Practice Address - Street 1:400 GIDNEY AVE
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-3760
Practice Address - Country:US
Practice Address - Phone:845-561-1565
Practice Address - Fax:845-561-1578
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY024733OtherNY LICENSE