Provider Demographics
NPI:1205046414
Name:KELLY, BRANDI J (MD)
Entity type:Individual
Prefix:DR
First Name:BRANDI
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:830 W BAYOU PINES DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-7097
Mailing Address - Country:US
Mailing Address - Phone:337-436-9557
Mailing Address - Fax:337-312-1311
Practice Address - Street 1:830 W BAYOU PINES DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7097
Practice Address - Country:US
Practice Address - Phone:337-436-9557
Practice Address - Fax:337-312-1311
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAMD.201854207ZP0102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1214671Medicaid