Healthcare Provider Details

I. General information

NPI: 1689823742
Provider Name (Legal Business Name): KELLY A PONCHERI DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4712 EXPLORATION AVE
LAKELAND FL
33812-3319
US

IV. Provider business mailing address

5050 S FLORIDA AVE
LAKELAND FL
33813-2501
US

V. Phone/Fax

Practice location:
  • Phone: 863-644-1313
  • Fax:
Mailing address:
  • Phone: 863-644-1313
  • Fax: 239-278-1159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC006075
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: