Healthcare Provider Details

I. General information

NPI: 1851593024
Provider Name (Legal Business Name): KELLEY MAREE LANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2633 CENTENNIAL BLVD SUITE 100
TALLAHASSEE FL
32308-0585
US

IV. Provider business mailing address

2633 CENTENNIAL BLVD SUITE 100
TALLAHASSEE FL
32308-0585
US

V. Phone/Fax

Practice location:
  • Phone: 850-431-5404
  • Fax: 850-431-4794
Mailing address:
  • Phone: 850-431-5404
  • Fax: 850-431-4794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberME104789
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME104789
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: