Provider Demographics
NPI:1932334307
Name:KELLY, LINDA L
Entity Type:Individual
Prefix:MS
First Name:LINDA
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2741 MASON RD
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13480-2131
Mailing Address - Country:US
Mailing Address - Phone:315-861-5151
Mailing Address - Fax:
Practice Address - Street 1:2741 MASON RD
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:NY
Practice Address - Zip Code:13480-2131
Practice Address - Country:US
Practice Address - Phone:315-861-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY485985163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse