Provider Demographics
NPI:1912126806
Name:KELLEHER, RUTH ELLEN (NP)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:ELLEN
Last Name:KELLEHER
Suffix:
Gender:F
Credentials:NP
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 14890
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-4890
Mailing Address - Country:US
Mailing Address - Phone:518-525-5634
Mailing Address - Fax:
Practice Address - Street 1:1 TALLOW WOOD DR
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065
Practice Address - Country:US
Practice Address - Phone:518-688-0434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380828363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01879189Medicaid
NYDD6363Medicare ID - Type Unspecified
NYS30752Medicare UPIN