Basic Information
| Provider Information | |||||||||
| NPI: | 1164652467 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6255 SHERIDAN DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142214836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168578666 | ||||||||
| FaxNumber: | 7166301054 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 LIMESTONE DR | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142217051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166302517 | ||||||||
| FaxNumber: | 7166345650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2009 | ||||||||
| LastUpdateDate: | 09/29/2015 | ||||||||
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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 | 363A00000X | 013309-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 013309-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.