Provider Demographics
NPI:1467874263
Name:MISTRETTA, KELLEY SHANNON (MS, RN, ANP, C-EFM)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:SHANNON
Last Name:MISTRETTA
Suffix:
Gender:F
Credentials:MS, RN, ANP, C-EFM
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:SHANNON
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RN, ANP, C-EFM
Mailing Address - Street 1:2157 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-2648
Mailing Address - Country:US
Mailing Address - Phone:716-862-1984
Mailing Address - Fax:
Practice Address - Street 1:2157 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2648
Practice Address - Country:US
Practice Address - Phone:716-862-1984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306653-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health