Provider Demographics
NPI:1962477448
Name:DWYER, KELLY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:DWYER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BUFFALO AVE
Mailing Address - Street 2:
Mailing Address - City:EAST ATLANTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-1028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 E 42ND ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-5405
Practice Address - Country:US
Practice Address - Phone:212-867-0405
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX011007-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV07349Medicare UPIN
NYX03E8EN611Medicare PIN