Healthcare Provider Details

I. General information

NPI: 1285216234
Provider Name (Legal Business Name): KELVIN DUPERA PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 NW 5TH AVE
OKEECHOBEE FL
34972-2568
US

IV. Provider business mailing address

308 NW 5TH AVE
OKEECHOBEE FL
34972-2568
US

V. Phone/Fax

Practice location:
  • Phone: 863-261-8354
  • Fax: 863-638-5637
Mailing address:
  • Phone: 863-261-8354
  • Fax: 863-638-5637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11012550
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9413104
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: