Provider Demographics
NPI:1982331427
Name:MCCOY, KELLY KEENAN (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:KEENAN
Last Name:MCCOY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:FREDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14063-1711
Mailing Address - Country:US
Mailing Address - Phone:716-679-8599
Mailing Address - Fax:
Practice Address - Street 1:33 CHURCH ST STE 3
Practice Address - Street 2:
Practice Address - City:FREDONIA
Practice Address - State:NY
Practice Address - Zip Code:14063-1761
Practice Address - Country:US
Practice Address - Phone:716-679-8599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-04
Last Update Date:2022-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY805337163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent