Provider Demographics
NPI:1700039203
Name:TRITES, KELLY ANNE (MS)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANNE
Last Name:TRITES
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 ROXBURY DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-1338
Mailing Address - Country:US
Mailing Address - Phone:631-858-0175
Mailing Address - Fax:
Practice Address - Street 1:67 ROXBURY DR
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-1338
Practice Address - Country:US
Practice Address - Phone:631-858-0175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor