Healthcare Provider Details

I. General information

NPI: 1083292874
Provider Name (Legal Business Name): KELLY NGUYEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 DAVIS BLVD STE 308
TAMPA FL
33606-3438
US

IV. Provider business mailing address

17 DAVIS BLVD STE 308
TAMPA FL
33606-3438
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-2201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberW8063
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number80726
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME173242
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME173242
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number35.156182
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: