Provider Demographics
NPI:1508663261
Name:KELLAR, TRACEY LEE
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:LEE
Last Name:KELLAR
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 GAFFNEY DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-1823
Mailing Address - Country:US
Mailing Address - Phone:315-836-1206
Mailing Address - Fax:
Practice Address - Street 1:420 GAFFNEY DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1823
Practice Address - Country:US
Practice Address - Phone:315-836-1206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist