Provider Demographics
NPI:1598420499
Name:KELLY, BRENNA JEAN
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:JEAN
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENNA
Other - Middle Name:JEAN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6086 N PALM AVE APT 10
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-1600
Mailing Address - Country:US
Mailing Address - Phone:559-970-8651
Mailing Address - Fax:
Practice Address - Street 1:1470 W HERNDON AVE STE 300
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-0552
Practice Address - Country:US
Practice Address - Phone:559-256-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker