Provider Demographics
NPI:1801317938
Name:KELLY, LAUREN (LAC MSAOM)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LAC MSAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5132 GENESEO MT MORRIS RD
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:NY
Mailing Address - Zip Code:14454
Mailing Address - Country:US
Mailing Address - Phone:585-568-7623
Mailing Address - Fax:
Practice Address - Street 1:5132 GENESEO MT MORRIS RD
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454
Practice Address - Country:US
Practice Address - Phone:585-568-7623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006032171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist