Healthcare Provider Details

I. General information

NPI: 1396660874
Provider Name (Legal Business Name): DEJON PAUL KELLY
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 VETERANS MEMORIAL HWY STE 10
COMMACK NY
11725-4300
US

IV. Provider business mailing address

11809 201ST PL
SAINT ALBANS NY
11412-3530
US

V. Phone/Fax

Practice location:
  • Phone: 516-585-7478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number030052
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: