Provider Demographics
NPI:1538527247
Name:LUPO, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LUPO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 GROVE AVE EXT
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-4922
Mailing Address - Country:US
Mailing Address - Phone:315-258-0118
Mailing Address - Fax:
Practice Address - Street 1:250 LAKE AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-5330
Practice Address - Country:US
Practice Address - Phone:315-255-8319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-09
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY674526163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse