Provider Demographics
NPI:1154966471
Name:HARE, KELLI
Entity type:Individual
Prefix:MISS
First Name:KELLI
Middle Name:
Last Name:HARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7157 ELLICOTT RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-9482
Mailing Address - Country:US
Mailing Address - Phone:716-720-0240
Mailing Address - Fax:
Practice Address - Street 1:7157 ELLICOTT RD
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-9482
Practice Address - Country:US
Practice Address - Phone:716-720-0240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7157174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7157Medicaid