Provider Demographics
NPI:1619230455
Name:ANDERSON, KELLY ELIZABETH
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:ANDERSON
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 1:4635 UNION RD
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1851
Mailing Address - Country:US
Mailing Address - Phone:716-505-5700
Mailing Address - Fax:716-633-9631
Practice Address - Street 1:140 MALL BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750-2014
Practice Address - Country:US
Practice Address - Phone:716-763-9070
Practice Address - Fax:716-763-3580
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist