Provider Demographics
NPI:1669851093
Name:JENNINGS, KELLI ANNE
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANNE
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:ANNE
Other - Last Name:BARRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:83 TREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3861
Mailing Address - Country:US
Mailing Address - Phone:631-714-4025
Mailing Address - Fax:
Practice Address - Street 1:90 AIR PARK DR
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7360
Practice Address - Country:US
Practice Address - Phone:631-580-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY497254041174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist