Basic Information
| Provider Information | |||||||||
| NPI: | 1881730489 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAROTTA | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 488 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142400488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6685395518 | ||||||||
| FaxNumber: | 2039161041 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 YOUNGS RD STE 202 | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166369004 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 521501 | NY | N | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant | 363L00000X | 335120 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 02869432 | 05 | NY | MEDICAID |