Provider Demographics
NPI:1013272939
Name:KELLEY, KRISTEN (DO)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PARK STREET
Mailing Address - Street 2:GLENS FALLS HOSPITAL - CREDENTIALING
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:1134 STATE ROUTE 29
Practice Address - Street 2:GREENWICH FAMILY HEALTH CENTER
Practice Address - City:GREENWICH
Practice Address - State:NY
Practice Address - Zip Code:12834-6107
Practice Address - Country:US
Practice Address - Phone:518-692-9861
Practice Address - Fax:518-692-7947
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY280120207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program