Provider Demographics
NPI:1598027054
Name:KELLEY, BRIAN P
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
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 1:98 CHAPMAN AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-4632
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:98 CHAPMAN AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-4632
Practice Address - Country:US
Practice Address - Phone:315-258-0650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306735164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse