Healthcare Provider Details

I. General information

NPI: 1124614789
Provider Name (Legal Business Name): KELLY MARIE O'BRIEN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2020
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4663 AUTUMNDALE DR
PACE FL
32571-1394
US

IV. Provider business mailing address

4663 AUTUMNDALE DR
PACE FL
32571-1394
US

V. Phone/Fax

Practice location:
  • Phone: 850-776-3325
  • Fax:
Mailing address:
  • Phone: 850-776-3325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN9196840
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11011201
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11011201
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: