Provider Demographics
NPI:1992114359
Name:BAXTER, KELLY ANNE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:BAXTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 COUNTY OFFICE BLDG 6
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:NY
Mailing Address - Zip Code:12413
Mailing Address - Country:US
Mailing Address - Phone:518-622-9163
Mailing Address - Fax:518-622-8592
Practice Address - Street 1:905 COUNTY OFFICE BLG 6
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:NY
Practice Address - Zip Code:12413
Practice Address - Country:US
Practice Address - Phone:518-622-9163
Practice Address - Fax:518-622-8592
Is Sole Proprietor?:No
Enumeration Date:2014-08-10
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401758-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health