Provider Demographics
NPI:1285969683
Name:KELLY, BRIAN
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8230 138TH ST APT 6P
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1477
Mailing Address - Country:US
Mailing Address - Phone:646-510-5904
Mailing Address - Fax:
Practice Address - Street 1:3434 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1730
Practice Address - Country:US
Practice Address - Phone:347-857-9699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004042171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist