Provider Demographics
NPI:1255173373
Name:SHELLY, KELSEY (LPN)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:SHELLY
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 1:231 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:ELLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12428-1703
Mailing Address - Country:US
Mailing Address - Phone:845-443-1734
Mailing Address - Fax:
Practice Address - Street 1:231 CANAL ST
Practice Address - Street 2:
Practice Address - City:ELLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12428-1703
Practice Address - Country:US
Practice Address - Phone:845-443-1734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP06946600164W00000X
NY310992164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse