Provider Demographics
NPI:1760609382
Name:KELLY, CONNIE DIANE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:DIANE
Last Name:KELLY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 GIBSON HILL RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:NY
Mailing Address - Zip Code:13775-4425
Mailing Address - Country:US
Mailing Address - Phone:607-287-8668
Mailing Address - Fax:
Practice Address - Street 1:39 PEARL ST W
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:NY
Practice Address - Zip Code:13838-1330
Practice Address - Country:US
Practice Address - Phone:252-354-7622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332008-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS38146Medicare UPIN