Provider Demographics
NPI:1558313999
Name:KELLY, BROOKE K (DO)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:K
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 FOOTE AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-7077
Mailing Address - Country:US
Mailing Address - Phone:716-664-7558
Mailing Address - Fax:716-664-7559
Practice Address - Street 1:207 FOOTE AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-7077
Practice Address - Country:US
Practice Address - Phone:716-664-7558
Practice Address - Fax:716-664-7559
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206222208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01933522Medicaid
NYRA7024Medicare PIN
NY01933522Medicaid