Healthcare Provider Details

I. General information

NPI: 1851094270
Provider Name (Legal Business Name): KELCY MCINTYRE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2023
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICOLLS RD
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

101 NICOLLS RD
STONY BROOK NY
11794-0001
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2020
  • Fax: 631-444-2894
Mailing address:
  • Phone: 631-444-2020
  • Fax: 631-444-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number342601
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: