Provider Demographics
NPI:1104017524
Name:BRAGAN, KELLY LYNN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:BRAGAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 INGLESID LANE
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090
Mailing Address - Country:US
Mailing Address - Phone:315-461-4240
Mailing Address - Fax:
Practice Address - Street 1:49 INGLESID LANE
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090
Practice Address - Country:US
Practice Address - Phone:315-461-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2621441164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02059754Medicaid