Provider Demographics
NPI:1780303339
Name:KELLY, KRISTEN MARIE (RN, FNP-C)
Entity type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN, FNP-C
Other - Prefix:MS
Other - First Name:KRISTEN
Other - Middle Name:M
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, FNP-C
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1834
Mailing Address - Country:US
Mailing Address - Phone:315-464-5162
Mailing Address - Fax:315-464-4613
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1834
Practice Address - Country:US
Practice Address - Phone:315-464-5162
Practice Address - Fax:315-464-4613
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF350064-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily