Provider Demographics
NPI:1922143163
Name:O'BRIEN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:O'BRIEN
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 1:328 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2011
Mailing Address - Country:US
Mailing Address - Phone:516-681-2020
Mailing Address - Fax:516-681-2410
Practice Address - Street 1:328 N BROADWAY
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2011
Practice Address - Country:US
Practice Address - Phone:516-681-2020
Practice Address - Fax:516-681-2410
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007945156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician