Provider Demographics
NPI:1477165017
Name:KELLY, SHERRI SUE (LPN)
Entity Type:Individual
Prefix:
First Name:SHERRI
Middle Name:SUE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:SHERRI
Other - Middle Name:SUE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:4214 KELLY LN
Mailing Address - Street 2:
Mailing Address - City:BURDETT
Mailing Address - State:NY
Mailing Address - Zip Code:14818-9805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4214 KELLY LN
Practice Address - Street 2:
Practice Address - City:BURDETT
Practice Address - State:NY
Practice Address - Zip Code:14818-9805
Practice Address - Country:US
Practice Address - Phone:607-351-4265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231570164W00000X
NY231570-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty