Provider Demographics
NPI:1902213044
Name:KELLEY, SHERRY LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:LYNN
Last Name:KELLEY
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 1:45 LAKE GEORGE RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:NY
Mailing Address - Zip Code:13684-3165
Mailing Address - Country:US
Mailing Address - Phone:315-562-4995
Mailing Address - Fax:
Practice Address - Street 1:45 LAKE GEORGE RD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:NY
Practice Address - Zip Code:13684-3165
Practice Address - Country:US
Practice Address - Phone:315-562-4995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102758-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse