Provider Demographics
NPI:1417462417
Name:KELLY, MEGAN RYAN
Entity Type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:RYAN
Last Name:KELLY
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 1:16 GREGORY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-1815
Mailing Address - Country:US
Mailing Address - Phone:716-432-7491
Mailing Address - Fax:
Practice Address - Street 1:236 BURTS RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:NY
Practice Address - Zip Code:13795-1731
Practice Address - Country:US
Practice Address - Phone:877-426-3307
Practice Address - Fax:877-426-3307
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042562-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics