Healthcare Provider Details

I. General information

NPI: 1720423445
Provider Name (Legal Business Name): KELLY LYN BRUNO LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 05/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 MARYCREST LANE(RIGHT)
WEST SENECA NY
14224
US

IV. Provider business mailing address

26 MARYCREST LN(RIGHT) 26 MARYCREST LANE (RIGHT)
WEST SENECA NY
14224
US

V. Phone/Fax

Practice location:
  • Phone: 716-844-8445
  • Fax:
Mailing address:
  • Phone: 716-844-8445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number281540-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: