Healthcare Provider Details

I. General information

NPI: 1407649957
Provider Name (Legal Business Name): BRIAN ISMAEL KELLY NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2025
Last Update Date: 07/26/2025
Certification Date: 07/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W ACACIA ST
STOCKTON CA
95203-2405
US

IV. Provider business mailing address

6701 SHOREWOOD LN
STOCKTON CA
95219-7004
US

V. Phone/Fax

Practice location:
  • Phone: 209-944-5550
  • Fax:
Mailing address:
  • Phone: 925-300-5917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95184031
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95184031
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: