Provider Demographics
NPI:1568830321
Name:BRUKIEWA, KELLY (PTA)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:BRUKIEWA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:O'MALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:39 LUFFING CT
Mailing Address - Street 2:
Mailing Address - City:ESSEX
Mailing Address - State:MD
Mailing Address - Zip Code:21221-2936
Mailing Address - Country:US
Mailing Address - Phone:443-602-0532
Mailing Address - Fax:
Practice Address - Street 1:7232 GERMAN HILL RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21222-1260
Practice Address - Country:US
Practice Address - Phone:410-282-6310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA3418225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant