Provider Demographics
NPI:1356615504
Name:KREIS, KELLY JOCELYN (RN, LMT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JOCELYN
Last Name:KREIS
Suffix:
Gender:F
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 ROUTE 347
Mailing Address - Street 2:SUITE 8D
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:516-381-0276
Mailing Address - Fax:
Practice Address - Street 1:2500 ROUTE 347
Practice Address - Street 2:SUITE 8D
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:516-381-0276
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY640956-1163WM1400X
NY020418-1163WM1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY020418-1OtherNYS LICENSED MASSAGE THERAPIST
527755-07OtherNATIONALLY CERTIFIED FOR THERAPEUTIC MASSAGE AND BODYWORK
NY6409561OtherNY REGISTERED PROFESSIONAL NURSE