Provider Demographics
NPI:1760680086
Name:KENLY, ALICE (LMT, LLCC)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:KENLY
Suffix:
Gender:F
Credentials:LMT, LLCC
Other - Prefix:
Other - First Name:FLUID
Other - Middle Name:
Other - Last Name:MOVES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:118 ARLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-6343
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:86 MEADOW ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-1607
Practice Address - Country:US
Practice Address - Phone:315-853-4285
Practice Address - Fax:315-853-4285
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014560-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist