Provider Demographics
NPI:1972028991
Name:THOMAS, KELLY L (LICENSED PRACTICAL N)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:L
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LICENSED PRACTICAL N
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:HOWLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 GLENRIDGE RD STE E
Mailing Address - Street 2:
Mailing Address - City:GLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12302
Mailing Address - Country:US
Mailing Address - Phone:518-370-1515
Mailing Address - Fax:518-370-1823
Practice Address - Street 1:19 GLENRIDGE RD STE E
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12302
Practice Address - Country:US
Practice Address - Phone:518-370-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2017-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY317256-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse