Provider Demographics
NPI:1881097749
Name:DAHLMAN GROSSMAN, KELLY (LPN)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:DAHLMAN GROSSMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:DAHLMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:15 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:NY
Mailing Address - Zip Code:12776-6414
Mailing Address - Country:US
Mailing Address - Phone:607-498-5335
Mailing Address - Fax:
Practice Address - Street 1:15 PARK AVE
Practice Address - Street 2:
Practice Address - City:ROSCOE
Practice Address - State:NY
Practice Address - Zip Code:12776-6414
Practice Address - Country:US
Practice Address - Phone:607-498-5335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY290180-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse