Provider Demographics
NPI:1982067195
Name:KELLY, STEPHANIE MARIE (LPN)
Entity Type:Individual
Prefix:MISS
First Name:STEPHANIE
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5626 BUNBURY TER
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-6910
Mailing Address - Country:US
Mailing Address - Phone:315-450-1739
Mailing Address - Fax:
Practice Address - Street 1:5626 BUNBURY TER
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-6910
Practice Address - Country:US
Practice Address - Phone:315-450-1739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297078-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse