Healthcare Provider Details

I. General information

NPI: 1376856658
Provider Name (Legal Business Name): FLORIDA ATLANTIC UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 8TH ST
WEST PALM BEACH FL
33401-3606
US

IV. Provider business mailing address

720 8TH ST
WEST PALM BEACH FL
33401-3606
US

V. Phone/Fax

Practice location:
  • Phone: 561-803-8880
  • Fax: 877-409-1795
Mailing address:
  • Phone: 561-803-8880
  • Fax: 877-409-1795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code364SS0200X
TaxonomySchool Clinical Nurse Specialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: LOUISA PONTIROLI KELLY
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 561-803-8880