Provider Demographics
NPI:1588200729
Name:TELLER, KELLY KRISTINE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KRISTINE
Last Name:TELLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2045
Mailing Address - Country:US
Mailing Address - Phone:315-342-9575
Mailing Address - Fax:
Practice Address - Street 1:1210 MAYFLOWER AVE # 3
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-6110
Practice Address - Country:US
Practice Address - Phone:917-284-3847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-22
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist