Provider Demographics
NPI:1811399348
Name:CONKLIN, KELLI MARIE
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:CONKLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:SATTERFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:449 IVORY RD
Mailing Address - Street 2:
Mailing Address - City:FREWSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14738
Mailing Address - Country:US
Mailing Address - Phone:716-467-2398
Mailing Address - Fax:
Practice Address - Street 1:449 IVORY RD
Practice Address - Street 2:
Practice Address - City:FREWSBURG
Practice Address - State:NY
Practice Address - Zip Code:14738-9724
Practice Address - Country:US
Practice Address - Phone:716-467-2398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315663372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider