Individual
EDWARD ROBERT KELLY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
512 N CAMPUS, ITHACA, NY 14853-6007
(607) 255-4237
Mailing address
214 E UPLAND RD, ITHACA, NY 14850-2255
(607) 255-4237
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
000039
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00039
NEW YORK SATE
NY
Enumeration date
09/10/2019
Last updated
09/10/2019
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