Healthcare Provider Details

I. General information

NPI: 1356253132
Provider Name (Legal Business Name): KELLY ANN HODGSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLY ANN LARA

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 COBBLE CRK
PENSACOLA FL
32504-8638
US

IV. Provider business mailing address

5067 TERRA LAKE CIR
PENSACOLA FL
32507-9087
US

V. Phone/Fax

Practice location:
  • Phone: 850-473-4800
  • Fax:
Mailing address:
  • Phone: 850-292-2874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: