Provider Demographics
NPI:1891999546
Name:COURTADE, KELLY N
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:COURTADE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5609 GREEN MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5887
Mailing Address - Country:US
Mailing Address - Phone:716-871-9883
Mailing Address - Fax:716-871-9887
Practice Address - Street 1:2565 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1939
Practice Address - Country:US
Practice Address - Phone:716-871-9883
Practice Address - Fax:716-871-9887
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013403-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist