Provider Demographics
NPI:1962816835
Name:GENTER, KELLY (MED)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GENTER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6979 MCCONNELL RD
Mailing Address - Street 2:
Mailing Address - City:GLENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:13343-9515
Mailing Address - Country:US
Mailing Address - Phone:315-405-7313
Mailing Address - Fax:
Practice Address - Street 1:6979 MCCONNELL RD
Practice Address - Street 2:
Practice Address - City:GLENFIELD
Practice Address - State:NY
Practice Address - Zip Code:13343-9515
Practice Address - Country:US
Practice Address - Phone:315-405-7313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY737297174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist