Healthcare Provider Details

I. General information

NPI: 1225859267
Provider Name (Legal Business Name): KEELY MICHELLE BROZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KEELY HARRIS

II. Dates (important events)

Enumeration Date: 10/22/2024
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 RACETRACK RD NW STE 100D
FORT WALTON BEACH FL
32547-1796
US

IV. Provider business mailing address

9643 BONE BLUFF DR
NAVARRE FL
32566-2551
US

V. Phone/Fax

Practice location:
  • Phone: 448-202-6100
  • Fax: 448-202-6101
Mailing address:
  • Phone: 850-637-3195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11046730
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ15184000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: