Healthcare Provider Details

I. General information

NPI: 1255397501
Provider Name (Legal Business Name): ANGELA WHITE KELLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 N PROSPECT AVE
LECANTO FL
34461-9792
US

IV. Provider business mailing address

1990 N PROSPECT AVE
LECANTO FL
34461-9792
US

V. Phone/Fax

Practice location:
  • Phone: 352-527-6888
  • Fax: 352-527-6888
Mailing address:
  • Phone: 352-527-6888
  • Fax: 352-527-8818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA0000001010
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105288
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: