Provider Demographics
NPI:1518393750
Name:KELLY, KRISTEN M (RN)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 LABRADOR DRIVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616
Mailing Address - Country:US
Mailing Address - Phone:585-749-0377
Mailing Address - Fax:
Practice Address - Street 1:3111 WINTON RD S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-2905
Practice Address - Country:US
Practice Address - Phone:585-749-0377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY603429372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider