Provider Demographics
NPI:1144835646
Name:INGHAM, KELLY M (RN, BSN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:INGHAM
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:HARBST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:693 STATE HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:GILBERTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13776-1104
Mailing Address - Country:US
Mailing Address - Phone:607-783-2207
Mailing Address - Fax:607-783-2254
Practice Address - Street 1:693 STATE HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:GILBERTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13776-1104
Practice Address - Country:US
Practice Address - Phone:607-783-2207
Practice Address - Fax:607-783-2254
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY632321163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool