Provider Demographics
NPI:1255577854
Name:MCDONOUGH, KELLY ANNE
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANNE
Last Name:MCDONOUGH
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 1:1796 BARD LN
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1506
Mailing Address - Country:US
Mailing Address - Phone:516-589-2280
Mailing Address - Fax:
Practice Address - Street 1:8460 PARSONS BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-2544
Practice Address - Country:US
Practice Address - Phone:718-298-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-02
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1488232174400000X
NY491578041390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No174400000XOther Service ProvidersSpecialist