Provider Demographics
NPI:1811241862
Name:KELLY, MANDY A (MSED)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 QUINTIN COURT
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-275-7059
Mailing Address - Fax:
Practice Address - Street 1:300 GARDEN CITY PLAZA
Practice Address - Street 2:SUITE 350
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-747-9030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY893451171M00000X
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator