Healthcare Provider Details

I. General information

NPI: 1629650486
Provider Name (Legal Business Name): KELSEY KORFHAGE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 LITTLE RD
TRINITY FL
34655-4421
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 727-846-7000
  • Fax:
Mailing address:
  • Phone: 727-846-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114332
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: