Healthcare Provider Details

I. General information

NPI: 1174080253
Provider Name (Legal Business Name): KELLY JO MCINTOSH-FREEMAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 S CONGRESS AVE STE 204
ATLANTIS FL
33462-6637
US

IV. Provider business mailing address

1109 CENTERSTONE LANE
RIVIERA BEACH FL
33404
US

V. Phone/Fax

Practice location:
  • Phone: 561-967-4118
  • Fax: 561-967-3463
Mailing address:
  • Phone: 561-891-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11006070
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9372881
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: