Provider Demographics
NPI:1871270371
Name:RANIEWICZ, KELLY BLAIR
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:BLAIR
Last Name:RANIEWICZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:BLAIR
Other - Last Name:JACOBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-873-1244
Practice Address - Street 1:1138 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14904-2502
Practice Address - Country:US
Practice Address - Phone:607-734-7982
Practice Address - Fax:607-734-1953
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352100363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily