Provider Demographics
NPI:1124312665
Name:CENNAME, KELLY MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:CENNAME
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:SANTOPIETRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2209 GENESEE ST.
Mailing Address - Street 2:BUSINESS OFFICE
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5930
Mailing Address - Country:US
Mailing Address - Phone:315-801-4238
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:2211 GENESEE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-5930
Practice Address - Country:US
Practice Address - Phone:315-801-8567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400058434Medicare PIN