Provider Demographics
NPI:1427496561
Name:MILLEA, KERRY ELIZABETH (ANP)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:ELIZABETH
Last Name:MILLEA
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:ELIZABETH
Other - Last Name:KEENAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:250 DELAWARE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1401
Practice Address - Country:US
Practice Address - Phone:518-439-8077
Practice Address - Fax:518-438-8070
Is Sole Proprietor?:No
Enumeration Date:2013-06-11
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306479-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03688415Medicaid
NY03688415Medicaid