Provider Demographics
NPI:1285923169
Name:WEST, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:WEST
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 1:168 WILSON RD.
Mailing Address - Street 2:
Mailing Address - City:SPARROWBUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12780
Mailing Address - Country:US
Mailing Address - Phone:845-591-9950
Mailing Address - Fax:
Practice Address - Street 1:115 BRICKMAN RD.
Practice Address - Street 2:
Practice Address - City:FALLSBURG
Practice Address - State:NY
Practice Address - Zip Code:12733
Practice Address - Country:US
Practice Address - Phone:845-434-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007704-1390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program