Provider Demographics
NPI:1952687121
Name:BRUSH, KELLY A (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:BRUSH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15A OLD ROUTE 202
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-2852
Mailing Address - Country:US
Mailing Address - Phone:845-401-6524
Mailing Address - Fax:
Practice Address - Street 1:31 CAPTAIN FALDERMEYER DR
Practice Address - Street 2:
Practice Address - City:STONY POINT
Practice Address - State:NY
Practice Address - Zip Code:10980-3463
Practice Address - Country:US
Practice Address - Phone:845-401-6524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307341-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse