Provider Demographics
NPI:1568725083
Name:TRIPP, KELLEY LEIGH (MSED)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:LEIGH
Last Name:TRIPP
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 WILLOWBEND DR
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1115
Mailing Address - Country:US
Mailing Address - Phone:585-586-1343
Mailing Address - Fax:
Practice Address - Street 1:149 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1434
Practice Address - Country:US
Practice Address - Phone:585-377-2230
Practice Address - Fax:585-377-2243
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY722605961174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist