Provider Demographics
NPI:1215288832
Name:KELLY, SHANEEQUA
Entity type:Individual
Prefix:MRS
First Name:SHANEEQUA
Middle Name:
Last Name:KELLY
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 1:1153 SIMPSON STREET
Mailing Address - Street 2:6
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10459
Mailing Address - Country:US
Mailing Address - Phone:917-293-9488
Mailing Address - Fax:
Practice Address - Street 1:1153 SIMPSON STREET
Practice Address - Street 2:6
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10459
Practice Address - Country:US
Practice Address - Phone:917-293-9488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist