Provider Demographics
NPI:1164509253
Name:KELLY, BRIELLE E (LAC, DIPLOM)
Entity type:Individual
Prefix:
First Name:BRIELLE
Middle Name:E
Last Name:KELLY
Suffix:
Gender:F
Credentials:LAC, DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 EL CAMINO REAL
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-2451
Mailing Address - Country:US
Mailing Address - Phone:650-596-5616
Mailing Address - Fax:650-596-5653
Practice Address - Street 1:10 EL CAMINO REAL
Practice Address - Street 2:SUITE 202
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-2451
Practice Address - Country:US
Practice Address - Phone:650-596-5616
Practice Address - Fax:650-596-5653
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001912171100000X
CA10375171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist