Provider Demographics
NPI:1104132547
Name:KELLY, BRENTNIE LAURIE (RN)
Entity type:Individual
Prefix:
First Name:BRENTNIE
Middle Name:LAURIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 LORING AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-2710
Mailing Address - Country:US
Mailing Address - Phone:716-335-2975
Mailing Address - Fax:
Practice Address - Street 1:232 LORING AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-2710
Practice Address - Country:US
Practice Address - Phone:716-335-2975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY594962163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health