Provider Demographics
NPI:1730550724
Name:BUSH, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:528 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:NY
Mailing Address - Zip Code:13135-2056
Mailing Address - Country:US
Mailing Address - Phone:315-341-8923
Mailing Address - Fax:
Practice Address - Street 1:528 MAIN ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:NY
Practice Address - Zip Code:13135-2056
Practice Address - Country:US
Practice Address - Phone:315-341-8923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284235164W00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No251E00000XAgenciesHome Health