Healthcare Provider Details

I. General information

NPI: 1023425493
Provider Name (Legal Business Name): KELLY HURST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 DELTONA BLVD
SAINT AUGUSTINE FL
32086-4203
US

IV. Provider business mailing address

25 DELTONA BLVD
SAINT AUGUSTINE FL
32086-4203
US

V. Phone/Fax

Practice location:
  • Phone: 904-794-0268
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number07-1582-000-05
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: