Provider Demographics
NPI:1982703674
Name:RAUSCH, KELLY MARIE (PNP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MARIE
Last Name:RAUSCH
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1009
Mailing Address - Country:US
Mailing Address - Phone:716-323-0034
Mailing Address - Fax:716-323-0292
Practice Address - Street 1:1021 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14212-1460
Practice Address - Country:US
Practice Address - Phone:716-852-1578
Practice Address - Fax:716-852-5154
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY441200163W00000X
NYF381753363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00027206901OtherUNIVERA
NY9512852OtherIHA
NY02665525Medicaid
NY080407000087OtherFIDELIS
NY000560953001OtherBC/BS
NY050816000026OtherFIDELIS
NY050816000026OtherFIDELIS
NY080407000087OtherFIDELIS