Healthcare Provider Details

I. General information

NPI: 1992279996
Provider Name (Legal Business Name): COLLEEN O'KENNEDY SELETOS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: COLLEEN MARIE O'KENNEDY

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2044 TRINITY OAKS BLVD STE 220
TRINITY FL
34655-4406
US

IV. Provider business mailing address

2044 TRINITY OAKS BLVD STE 220
TRINITY FL
34655-4406
US

V. Phone/Fax

Practice location:
  • Phone: 727-645-6900
  • Fax: 727-372-8989
Mailing address:
  • Phone: 727-645-6900
  • Fax: 727-372-8989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9111933
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: