Provider Demographics
NPI:1972961886
Name:KELLY, NINA CECELIA (LPN)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:CECELIA
Last Name:KELLY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:NINA
Other - Middle Name:C
Other - Last Name:MCCREARY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:29 DREXEL RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-2801
Mailing Address - Country:US
Mailing Address - Phone:716-804-1027
Mailing Address - Fax:
Practice Address - Street 1:29 DREXEL RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2801
Practice Address - Country:US
Practice Address - Phone:716-804-1027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263364164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse