Provider Demographics
NPI:1538188966
Name:WALKER, KELLY A (CNM)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:WALKER
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:CARAMORE-WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:90 PRESIDENTIAL PLZ
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2240
Mailing Address - Country:US
Mailing Address - Phone:315-464-5210
Mailing Address - Fax:315-464-2141
Practice Address - Street 1:70 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3502
Practice Address - Country:US
Practice Address - Phone:631-361-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF0007251367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02226277Medicaid
NYRB3790Medicare PIN