Provider Demographics
NPI:1760491872
Name:STEWART, KELLY LYNN (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:STEWART
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 FLY ROAD
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057
Mailing Address - Country:US
Mailing Address - Phone:315-464-1849
Mailing Address - Fax:315-464-1709
Practice Address - Street 1:6620 FLY ROAD
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:315-464-1849
Practice Address - Fax:315-464-1709
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY509703-1163W00000X
NYF334403-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q53519Medicare UPIN