Provider Demographics
NPI:1881566420
Name:KELLY, PETA
Entity type:Individual
Prefix:
First Name:PETA
Middle Name:
Last Name:KELLY
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 1:20 CORNELIUS RD
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951-3902
Mailing Address - Country:US
Mailing Address - Phone:347-484-7130
Mailing Address - Fax:
Practice Address - Street 1:44 COURT ST STE 1217
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-4410
Practice Address - Country:US
Practice Address - Phone:347-479-1868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-23
Last Update Date:2025-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist