Provider Demographics
NPI:1871270371
Name:RANIEWICZ, KELLY BLAIR
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:BLAIR
Last Name:RANIEWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:BLAIR
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 IVY ST STE 206
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14905-1627
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-271-2071
Practice Address - Street 1:600 ROE AVE
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14905-1676
Practice Address - Country:US
Practice Address - Phone:607-737-8165
Practice Address - Fax:607-737-8175
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily