Provider Demographics
NPI:1194213785
Name:KELLEY, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KELLEY
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 1:3133 NAPOLEON AVE
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-5119
Mailing Address - Country:US
Mailing Address - Phone:318-572-2829
Mailing Address - Fax:
Practice Address - Street 1:102 MASON FARM RD
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-6134
Practice Address - Country:US
Practice Address - Phone:919-966-1459
Practice Address - Fax:919-843-2356
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-29
Last Update Date:2018-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC50147606390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program