Healthcare Provider Details

I. General information

NPI: 1295648053
Provider Name (Legal Business Name): RAVEN KELLY MSN, APRN, AGPCNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2473 CARE DR STE 102
TALLAHASSEE FL
32308-9815
US

IV. Provider business mailing address

2473 CARE DR STE 102
TALLAHASSEE FL
32308-9815
US

V. Phone/Fax

Practice location:
  • Phone: 850-431-5001
  • Fax:
Mailing address:
  • Phone: 850-431-5001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11048513
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: