Healthcare Provider Details

I. General information

NPI: 1710341557
Provider Name (Legal Business Name): KELLY TRAYLOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4266 SUNBEAM RD
JACKSONVILLE FL
32257-6030
US

IV. Provider business mailing address

4348 SOUTHPOINT BLVD STE 100
JACKSONVILLE FL
32216-0986
US

V. Phone/Fax

Practice location:
  • Phone: 904-407-7710
  • Fax: 904-407-8131
Mailing address:
  • Phone: 904-281-1915
  • Fax: 904-281-1119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9258734
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9258734
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: