Provider Demographics
NPI:1730423575
Name:BROWN, KELLIE M (MA)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:M
Last Name:BROWN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 BAYCHESTER AVE APT 17C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10475-1713
Mailing Address - Country:US
Mailing Address - Phone:917-843-9301
Mailing Address - Fax:
Practice Address - Street 1:900 BAYCHESTER AVE APT 17C
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1713
Practice Address - Country:US
Practice Address - Phone:917-843-9301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-17
Last Update Date:2012-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY815126174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist