Provider Demographics
NPI:1912217027
Name:SERVELLO, KELLY ANN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:SERVELLO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-2017
Mailing Address - Country:US
Mailing Address - Phone:315-717-7442
Mailing Address - Fax:315-895-0062
Practice Address - Street 1:63 S 5TH AVE
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-2017
Practice Address - Country:US
Practice Address - Phone:315-717-7442
Practice Address - Fax:315-895-0062
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009449-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist