Provider Demographics
NPI:1588072474
Name:WILMARTH, KELLY (C-FNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WILMARTH
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2065
Mailing Address - Country:US
Mailing Address - Phone:607-754-9870
Mailing Address - Fax:607-785-9862
Practice Address - Street 1:401 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2065
Practice Address - Country:US
Practice Address - Phone:607-754-9870
Practice Address - Fax:607-785-9862
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338979363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner