Provider Demographics
NPI:1811417710
Name:LEVEILLE, KELLIE (NP-C, CNM)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:LEVEILLE
Suffix:
Gender:F
Credentials:NP-C, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:BLAUVELT
Mailing Address - State:NY
Mailing Address - Zip Code:10913-0047
Mailing Address - Country:US
Mailing Address - Phone:772-834-2444
Mailing Address - Fax:
Practice Address - Street 1:160 N MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1912
Practice Address - Country:US
Practice Address - Phone:845-348-2550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-21
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367A00000X
NY341621363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE