Provider Demographics
NPI:1316946494
Name:KELLY, JUDY (FNP)
Entity type:Individual
Prefix:MRS
First Name:JUDY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:427 GUY PARK AVE - PRIMARY & SPECIALTY CARE DEPT.
Mailing Address - Street 2:ST. MARY'S HOSPITAL @ AMSTERDAM
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010
Mailing Address - Country:US
Mailing Address - Phone:518-841-7430
Mailing Address - Fax:518-841-7121
Practice Address - Street 1:ST. MARY'S HOSP. FAM. HLTH. CTR. AT JOHNSVILLE
Practice Address - Street 2:7 TIMMERMAN AVENUE
Practice Address - City:ST. JOHNSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13452
Practice Address - Country:US
Practice Address - Phone:518-568-7145
Practice Address - Fax:518-568-7147
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330791-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY141347719OtherUHC
NY970803OtherMVP
NY02406673Medicaid
S06708Medicare UPIN
NY02406673Medicaid