Healthcare Provider Details

I. General information

NPI: 1699621029
Provider Name (Legal Business Name): KELLY ANN ANTONIAK FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 W VIRGINIA AVE
TAMPA FL
33607-6357
US

IV. Provider business mailing address

218 LOTUS DR
SAFETY HARBOR FL
34695-4718
US

V. Phone/Fax

Practice location:
  • Phone: 813-544-3208
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11045692
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: