Provider Demographics
NPI:1215154968
Name:WOOLSON, KELLY LEWIS (LPN)
Entity type:Individual
Prefix:MR
First Name:KELLY
Middle Name:LEWIS
Last Name:WOOLSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 SHORE OAKS DR
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-6230
Mailing Address - Country:US
Mailing Address - Phone:315-343-0370
Mailing Address - Fax:
Practice Address - Street 1:146 SHORE OAKS DR
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-6230
Practice Address - Country:US
Practice Address - Phone:315-343-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245024164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01826324Medicaid