Provider Demographics
NPI:1467486811
Name:KELLY, AMY (CFNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 ROUTE 9
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-4904
Mailing Address - Country:US
Mailing Address - Phone:845-298-7022
Mailing Address - Fax:845-298-7022
Practice Address - Street 1:1323 ROUTE 9
Practice Address - Street 2:SUITE 204
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-4904
Practice Address - Country:US
Practice Address - Phone:845-298-7022
Practice Address - Fax:845-298-7022
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF331971363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02043043Medicaid
NY9SV571Medicare ID - Type Unspecified
NY02043043Medicaid