1477165017 NPI number — SHERRI SUE KELLY LPN

Table of content: SHERRI SUE KELLY LPN (NPI 1477165017)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477165017 NPI number — SHERRI SUE KELLY LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLY
Provider First Name:
SHERRI
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLY
Provider Other First Name:
SHERRI
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1477165017
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4214 KELLY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURDETT
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14818-9805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4214 KELLY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURDETT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14818-9805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-351-4265
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , with the licence number:  231570 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 164W00000X , with the licence number: 231570-01 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)