Healthcare Provider Details

I. General information

NPI: 1174450191
Provider Name (Legal Business Name): KELLY KENNEDY-BAUZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 ARISTA DR
DIX HILLS NY
11746-4920
US

IV. Provider business mailing address

1985 MARCUS AVE STE 100
NEW HYDE PARK NY
11042-2025
US

V. Phone/Fax

Practice location:
  • Phone: 631-683-4393
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: