Provider Demographics
NPI:1053034777
Name:AMEDICK, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:AMEDICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9484 PUTNAM RD
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-9797
Mailing Address - Country:US
Mailing Address - Phone:585-815-3820
Mailing Address - Fax:
Practice Address - Street 1:278 BANK ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1616
Practice Address - Country:US
Practice Address - Phone:585-344-0584
Practice Address - Fax:585-300-4526
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228612164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse