Provider Demographics
NPI:1134383946
Name:KELLEY, DELOISA I (PMHNP)
Entity type:Individual
Prefix:
First Name:DELOISA
Middle Name:I
Last Name:KELLEY
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1446
Mailing Address - Country:US
Mailing Address - Phone:585-919-0014
Mailing Address - Fax:585-919-0014
Practice Address - Street 1:42 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1446
Practice Address - Country:US
Practice Address - Phone:585-919-0014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-11
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
NY404488363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01420800Medicaid