Provider Demographics
NPI:1538691670
Name:KELLY, DANIELLE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:MARIE
Other - Last Name:TOLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:21 BLOOMINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1504
Practice Address - Country:US
Practice Address - Phone:914-682-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-29
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY3091882084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1538691670Medicaid