Provider Demographics
NPI:1821807553
Name:KELLEY, CARRIE (RN)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 104
Mailing Address - Street 2:
Mailing Address - City:PARISH
Mailing Address - State:NY
Mailing Address - Zip Code:13131-0104
Mailing Address - Country:US
Mailing Address - Phone:315-236-6262
Mailing Address - Fax:
Practice Address - Street 1:179 COUNTY ROUTE 64
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:NY
Practice Address - Zip Code:13114-4219
Practice Address - Country:US
Practice Address - Phone:315-236-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY966663163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse