Healthcare Provider Details

I. General information

NPI: 1922549104
Provider Name (Legal Business Name): KELLY CORNNELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E BRANDON BLVD
BRANDON FL
33511-5222
US

IV. Provider business mailing address

5901 E FOWLER AVE STE 100
TEMPLE TERRACE FL
33617-2305
US

V. Phone/Fax

Practice location:
  • Phone: 813-978-9700
  • Fax:
Mailing address:
  • Phone: 813-978-9700
  • Fax: 813-558-6185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9110185
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: