Basic Information
| Provider Information | |||||||||
| NPI: | 1932212412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRIDDLE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 E STATE ST | ||||||||
| Address2: | PO BOX 1250 | ||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120781203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187735729 | ||||||||
| FaxNumber: | 5187735620 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 E STATE ST | ||||||||
| Address2: | MAB-GPCC | ||||||||
| City: | GLOVERSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120781203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187735729 | ||||||||
| FaxNumber: | 5187735620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 01/21/2015 | ||||||||
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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 | 367A00000X | F001126 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 6007701 | 01 | NY | MVP HEALTHPLAN | OTHER | 000404812003 | 01 | NY | BSH NE NY | OTHER | 02459887 | 05 | NY | MEDICAID |