MEDICARE: KIMBERLYN NANETTA KELLEY OTD, OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	10652	FL

General Provider Information

NPI Number	:	1336324110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLYN NANETTA KELLEY OTD, OTR/L

Provider Business Mailing Address
First Line	:	2916 HABANA WAY
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33614-7108
Country	:	US
Telephone Number	:	813-846-9788
Fax Number	:

Provider Business Practice Location Address
First Line	:	8517 BROKEN WILLOW CT
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647
Country	:	US
Telephone Number	:	813-846-9788
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2007
Last Update Date	:	03/31/2015

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