Provider Demographics
NPI:1134569296
Name:BACCARI, KELLY M
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:BACCARI
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 1:1784 CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-2904
Mailing Address - Country:US
Mailing Address - Phone:516-659-8533
Mailing Address - Fax:
Practice Address - Street 1:1784 CARROLL AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-2904
Practice Address - Country:US
Practice Address - Phone:516-659-8533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program