Basic Information
| Provider Information | |||||||||
| NPI: | 1669451761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W FAYETTE ST | ||||||||
| Address2: | STE 400 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132042859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154721488 | ||||||||
| FaxNumber: | 3154728060 | ||||||||
| Practice Location | |||||||||
| Address1: | 436 HINSDALE RD | ||||||||
| Address2: | |||||||||
| City: | CAMILLUS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130311648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154880996 | ||||||||
| FaxNumber: | 3154881955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 05/12/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F303673 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.