Provider Demographics
NPI:1821369208
Name:KELLY, TIFFANEY (LPN)
Entity Type:Individual
Prefix:
First Name:TIFFANEY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 AFFINITY LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-1702
Mailing Address - Country:US
Mailing Address - Phone:585-490-7284
Mailing Address - Fax:
Practice Address - Street 1:226 AFFINITY LN
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-1702
Practice Address - Country:US
Practice Address - Phone:585-490-7284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300826164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse