Provider Demographics
NPI:1902234917
Name:DORMAN, KELLY MARIA (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIA
Last Name:DORMAN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:MARIA
Other - Last Name:MCNICHOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PMHNP
Mailing Address - Street 1:1021 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-2837
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1021 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:ONEIDA
Practice Address - State:NY
Practice Address - Zip Code:13421-2837
Practice Address - Country:US
Practice Address - Phone:315-744-6977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-30
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY645763163W00000X
PASP022693363LP0808X
NY401708363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04003563Medicaid