Basic Information
| Provider Information | |||||||||
| NPI: | 1083783278 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 571 SAINT JOSEPHS BLVD FL 2 | ||||||||
| Address2: | |||||||||
| City: | ELMIRA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 149013230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072712050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8 DENISON PKWY E | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | CORNING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148302638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6079364143 | ||||||||
| FaxNumber: | 6079366836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 06/13/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F335005 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 335005 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 02843209 | 05 | NY | MEDICAID |