Provider Demographics
NPI:1497316103
Name:KELLY, SUSHEIAN SAMANTHA (MD/MSCR)
Entity type:Individual
Prefix:MRS
First Name:SUSHEIAN
Middle Name:SAMANTHA
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD/MSCR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 EAST 210 ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467
Mailing Address - Country:US
Mailing Address - Phone:718-223-0127
Mailing Address - Fax:
Practice Address - Street 1:111 EAST 210 ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-223-0127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program