Healthcare Provider Details

I. General information

NPI: 1083847446
Provider Name (Legal Business Name): SHEREE KEARNTA KELSO LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 09/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 NW 25TH ST STE 4
DORAL FL
33122-1623
US

IV. Provider business mailing address

7800 NW 25TH ST STE 4
DORAL FL
33122-1623
US

V. Phone/Fax

Practice location:
  • Phone: 305-593-2174
  • Fax: 305-593-1417
Mailing address:
  • Phone: 305-593-2174
  • Fax: 305-593-1417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5153136
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: