Healthcare Provider Details

I. General information

NPI: 1285558767
Provider Name (Legal Business Name): OLIVIA GRACE KELLY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 W 218TH ST
NEW YORK NY
10034-1005
US

IV. Provider business mailing address

30 PARK TER E
NEW YORK NY
10034-1513
US

V. Phone/Fax

Practice location:
  • Phone: 212-854-3178
  • Fax:
Mailing address:
  • Phone: 631-879-3973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number004195
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: