Healthcare Provider Details

I. General information

NPI: 1285624932
Provider Name (Legal Business Name): KELLY LYNN COLE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 NW 57TH ST
GAINESVILLE FL
32605-4482
US

IV. Provider business mailing address

1034 NW 57TH ST
GAINESVILLE FL
32605-4482
US

V. Phone/Fax

Practice location:
  • Phone: 352-519-5430
  • Fax: 352-333-6249
Mailing address:
  • Phone: 352-519-5430
  • Fax: 352-333-6249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103309
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: