Provider Demographics
NPI:1831484096
Name:EMERSON, KELLY NICOLE (LMT, PTA)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:NICOLE
Last Name:EMERSON
Suffix:
Gender:F
Credentials:LMT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 RED TAIL DR.
Mailing Address - Street 2:STE. 3 & 4
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-674-9600
Mailing Address - Fax:716-674-9700
Practice Address - Street 1:240 RED TAIL
Practice Address - Street 2:STE. 3 & 4
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1581
Practice Address - Country:US
Practice Address - Phone:716-674-9600
Practice Address - Fax:716-674-9700
Is Sole Proprietor?:No
Enumeration Date:2011-06-16
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019962225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist