Provider Demographics
NPI:1730414111
Name:KELLY, MALLORY LYNN (RPA-C)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:RPA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:290 CENTER RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1945
Mailing Address - Country:US
Mailing Address - Phone:716-675-7693
Mailing Address - Fax:855-714-1253
Practice Address - Street 1:290 CENTER RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-1945
Practice Address - Country:US
Practice Address - Phone:716-675-7693
Practice Address - Fax:855-714-1253
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY013603363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant