Healthcare Provider Details

I. General information

NPI: 1124262340
Provider Name (Legal Business Name): KERRY KATHLEEN KELLY ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 05/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6261 NW 6TH WAY SUITE 110
FORT LAUDERDALE FL
33309-6103
US

IV. Provider business mailing address

6261 NW 6TH WAY SUITE 110
FORT LAUDERDALE FL
33309-6103
US

V. Phone/Fax

Practice location:
  • Phone: 954-634-6400
  • Fax: 954-634-6444
Mailing address:
  • Phone: 954-634-6400
  • Fax: 954-634-6444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP3097652
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: