Provider Demographics
NPI:1669451761
Name:KELLY, JEAN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Mailing Address - Street 1:1001 W FAYETTE ST
Mailing Address - Street 2:STE 400
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-2859
Mailing Address - Country:US
Mailing Address - Phone:315-472-1488
Mailing Address - Fax:315-472-8060
Practice Address - Street 1:436 HINSDALE RD
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1648
Practice Address - Country:US
Practice Address - Phone:315-488-0996
Practice Address - Fax:315-488-1955
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF303673363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB3927Medicare PIN