Healthcare Provider Details

I. General information

NPI: 1578204319
Provider Name (Legal Business Name): BRIANNE NICHELLE KELLY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 W HARRISON ST
CHICAGO IL
60612-3801
US

IV. Provider business mailing address

1620 W HARRISON ST, CHICAGO
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5000
  • Fax:
Mailing address:
  • Phone: 312-942-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number036180581
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: