Provider Demographics
NPI:1710437892
Name:ANDERSON, KELLEY MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:KELLEY
Other - Middle Name:MARIE
Other - Last Name:GLOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:500 WHITE ROAD
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-9610
Mailing Address - Country:US
Mailing Address - Phone:585-944-4467
Mailing Address - Fax:
Practice Address - Street 1:500 WHITE ROAD
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-9610
Practice Address - Country:US
Practice Address - Phone:585-944-4467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY322767-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04550001Medicaid