Provider Demographics
NPI:1679363436
Name:DEMOREST- CLEMONS, KELLI S (LPN)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:S
Last Name:DEMOREST- CLEMONS
Suffix:
Gender:
Credentials:LPN
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:CLEMONS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:7032 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-9418
Mailing Address - Country:US
Mailing Address - Phone:716-957-6386
Mailing Address - Fax:716-957-6386
Practice Address - Street 1:7032 WHEELER RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-9418
Practice Address - Country:US
Practice Address - Phone:716-957-6386
Practice Address - Fax:716-957-6386
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352819164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse