Provider Demographics
NPI:1174574099
Name:REID-WALDOCK, KELLY (NP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:REID-WALDOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1295 PORTLAND AVENUE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-266-7560
Mailing Address - Fax:585-266-7916
Practice Address - Street 1:1295 PORTLAND AVENUE
Practice Address - Street 2:SUITE 7
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-266-7560
Practice Address - Fax:585-266-7916
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3324631363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02122425Medicaid
NP0242OtherPREFERRED CARE
0181925590OtherBLUE CHOICE
S87525Medicare UPIN
NY02122425Medicaid