Provider Demographics
NPI:1144938887
Name:KELLEY, AMANDA (MS, RN, AGCNS-BC)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MS, RN, AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 NORTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-4223
Mailing Address - Country:US
Mailing Address - Phone:315-651-6174
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3011
Practice Address - Country:US
Practice Address - Phone:585-729-4415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY661621-A163W00000X, 364S00000X
NY661621163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163W00000XNursing Service ProvidersRegistered Nurse