Healthcare Provider Details

I. General information

NPI: 1801603790
Provider Name (Legal Business Name): KELLY BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 ELLA ST
GRESHAM NE
68367-3028
US

IV. Provider business mailing address

PO BOX 115
GRESHAM NE
68367-0115
US

V. Phone/Fax

Practice location:
  • Phone: 402-750-9917
  • Fax:
Mailing address:
  • Phone: 402-750-9917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: