Provider Demographics
NPI:1932212412
Name:PRIDDLE, KELLY ANNE (CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:PRIDDLE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 E STATE ST
Mailing Address - Street 2:PO BOX 1250
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-1203
Mailing Address - Country:US
Mailing Address - Phone:518-773-5729
Mailing Address - Fax:518-773-5620
Practice Address - Street 1:99 E STATE ST
Practice Address - Street 2:MAB-GPCC
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078-1203
Practice Address - Country:US
Practice Address - Phone:518-773-5729
Practice Address - Fax:518-773-5620
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF001126367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6007701OtherMVP HEALTHPLAN
NY000404812003OtherBSH NE NY
NY02459887Medicaid
NYRB4254Medicare PIN
NY6007701OtherMVP HEALTHPLAN