Provider Demographics
NPI:1558855296
Name:KELLY, JACQUELINE A (NP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:251 SALINA MEADOWS PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-4516
Mailing Address - Country:US
Mailing Address - Phone:315-464-2000
Mailing Address - Fax:315-464-2010
Practice Address - Street 1:750 EAST ADAMS STREET
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:315-464-5979
Practice Address - Fax:315-464-4761
Is Sole Proprietor?:No
Enumeration Date:2018-06-17
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5010974363L00000X
NY348747363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily