Provider Demographics
NPI:1841873452
Name:REYNOLDS, KELLY MARIE (RN)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MARIE
Last Name:REYNOLDS
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 1:1445 KEMBLE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4441
Mailing Address - Country:US
Mailing Address - Phone:315-732-0100
Mailing Address - Fax:929-243-8133
Practice Address - Street 1:1445 KEMBLE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4441
Practice Address - Country:US
Practice Address - Phone:315-732-0100
Practice Address - Fax:929-243-8133
Is Sole Proprietor?:No
Enumeration Date:2021-04-30
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY760576-1163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology