Provider Demographics
NPI:1760787709
Name:KELLY, NICOLE K (PA)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:K
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:K
Other - Last Name:FALCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2 COATES DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6758
Mailing Address - Country:US
Mailing Address - Phone:845-651-1412
Mailing Address - Fax:845-651-1512
Practice Address - Street 1:30 HATFIELD LN
Practice Address - Street 2:STE 109
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6766
Practice Address - Country:US
Practice Address - Phone:845-692-3111
Practice Address - Fax:845-294-0118
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1095483OtherCERTIFICATION