Provider Demographics
NPI:1891565800
Name:KELLY, MICHELE A
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 REGINA DR
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-2402
Mailing Address - Country:US
Mailing Address - Phone:631-504-9562
Mailing Address - Fax:
Practice Address - Street 1:50 REGINA DR
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-2402
Practice Address - Country:US
Practice Address - Phone:631-504-9562
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1725123321174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist