Provider Demographics
NPI:1295528081
Name:PELLAM, KERRI L
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:L
Last Name:PELLAM
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 1:7485 HODGE RD
Mailing Address - Street 2:
Mailing Address - City:LOWVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13367-2332
Mailing Address - Country:US
Mailing Address - Phone:315-709-9065
Mailing Address - Fax:
Practice Address - Street 1:830 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4034
Practice Address - Country:US
Practice Address - Phone:315-709-9065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY771196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine