Provider Demographics
NPI:1861536369
Name:LADD, KELLY ANGEL (LPN)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANGEL
Last Name:LADD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:ANGEL
Other - Last Name:BANACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1019 COUNTY RTE 15
Mailing Address - Street 2:
Mailing Address - City:LACONA
Mailing Address - State:NY
Mailing Address - Zip Code:13083-3198
Mailing Address - Country:US
Mailing Address - Phone:315-569-2719
Mailing Address - Fax:
Practice Address - Street 1:1019 COUNTY RTE 15
Practice Address - Street 2:
Practice Address - City:LACONA
Practice Address - State:NY
Practice Address - Zip Code:13083-3198
Practice Address - Country:US
Practice Address - Phone:315-569-2719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY251564-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01812308Medicaid