Healthcare Provider Details

I. General information

NPI: 1790319994
Provider Name (Legal Business Name): COREEN KELLY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 MASON AVE
DAYTONA BEACH FL
32117-4551
US

IV. Provider business mailing address

1862 SILVER FERN RD
PORT ORANGE FL
32128-6741
US

V. Phone/Fax

Practice location:
  • Phone: 386-274-2000
  • Fax: 386-274-2009
Mailing address:
  • Phone: 518-409-3502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11006345
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: