Provider Demographics
NPI:1144974023
Name:CLIFFORD, KELLY A
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:CLIFFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11978-1011
Mailing Address - Country:US
Mailing Address - Phone:631-599-3690
Mailing Address - Fax:
Practice Address - Street 1:WESTHAMPTON CARE CENTER
Practice Address - Street 2:78 OLD COUNTRY ROAD
Practice Address - City:WESTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11977
Practice Address - Country:US
Practice Address - Phone:631-288-0101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY34265601164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse