Provider Demographics
NPI:1578348249
Name:DEFRAIA, KELLY HACKETT (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:HACKETT
Last Name:DEFRAIA
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 1:7 RIP VAN LN
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3006
Mailing Address - Country:US
Mailing Address - Phone:914-456-1341
Mailing Address - Fax:
Practice Address - Street 1:7 RIP VAN LN
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-3006
Practice Address - Country:US
Practice Address - Phone:914-456-1341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY566919163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool