Provider Demographics
NPI:1639725518
Name:KILLIKELLY, CORETTA E
Entity Type:Individual
Prefix:
First Name:CORETTA
Middle Name:E
Last Name:KILLIKELLY
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:PO BOX 38077
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-8077
Mailing Address - Country:US
Mailing Address - Phone:518-334-2254
Mailing Address - Fax:
Practice Address - Street 1:125 WOLF RD STE 101
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1221
Practice Address - Country:US
Practice Address - Phone:518-334-2254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174H00000X
NY529069163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No174H00000XOther Service ProvidersHealth Educator